Healthcare Provider Details

I. General information

NPI: 1215501424
Provider Name (Legal Business Name): SELF INITIATED LIVING OPTIONS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2021
Last Update Date: 08/24/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3253 ROUTE 112 BLDG 10
MEDFORD NY
11763-1411
US

IV. Provider business mailing address

3253 ROUTE 112 BLDG 10
MEDFORD NY
11763-1411
US

V. Phone/Fax

Practice location:
  • Phone: 631-880-7929
  • Fax: 631-946-6377
Mailing address:
  • Phone: 631-880-7929
  • Fax: 631-946-6377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. JOSEPH DELGADO
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 631-880-7929