Healthcare Provider Details

I. General information

NPI: 1548433006
Provider Name (Legal Business Name): INDEPENDENT GROUP HOME LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2008
Last Update Date: 04/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 MOUTAUK HIGHWAY
EASTPORT NY
11941
US

IV. Provider business mailing address

221 N SUNRISE SERVICE RD
MANORVILLE NY
11949-9604
US

V. Phone/Fax

Practice location:
  • Phone: 631-878-8900
  • Fax: 631-878-8201
Mailing address:
  • Phone: 631-878-8900
  • Fax: 631-878-8201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. WALTER W. STOCKTON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 631-878-8900