Healthcare Provider Details

I. General information

NPI: 1427198209
Provider Name (Legal Business Name): CONCERN FOR INDEPENDENT LIVING, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 05/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 EXPRESSWAY DRIVE SOUTH
MEDFORD NY
11763
US

IV. Provider business mailing address

PO BOX 358 312 EXPRESSWAY DRIVE SOUTH
MEDFORD NY
11763
US

V. Phone/Fax

Practice location:
  • Phone: 631-750-2225
  • Fax: 631-758-0467
Mailing address:
  • Phone: 631-758-0474
  • Fax: 631-758-0467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number7609432
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. RALPH FASANO
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 631-758-0474