Healthcare Provider Details

I. General information

NPI: 1760568802
Provider Name (Legal Business Name): CIDNY-INDEPENDENT LIVING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 05/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 OCEAN PKWY ROOM 101
BROOKLYN NY
11218-2481
US

IV. Provider business mailing address

PO BOX 180032
BROOKLYN NY
11218-0032
US

V. Phone/Fax

Practice location:
  • Phone: 212-254-5000
  • Fax: 212-460-9194
Mailing address:
  • Phone: 212-254-5000
  • Fax: 212-460-9194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number0637L002
License Number StateNY

VIII. Authorized Official

Name: MR. KENNETH L BLOCK
Title or Position: MANAGING DIRECTOR
Credential:
Phone: 212-254-5000