Healthcare Provider Details

I. General information

NPI: 1376893941
Provider Name (Legal Business Name): ACTIVITIES OF DAILY LIVING HOME CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 DIANA DR
MASTIC BEACH NY
11951-6308
US

IV. Provider business mailing address

67 DIANA DR
MASTIC BEACH NY
11951-6308
US

V. Phone/Fax

Practice location:
  • Phone: 631-394-6639
  • Fax:
Mailing address:
  • Phone: 631-394-6639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number StateNY

VIII. Authorized Official

Name: KENDRA DENISE LEWIS
Title or Position: CNA
Credential:
Phone: 631-394-6639