Healthcare Provider Details

I. General information

NPI: 1275706731
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

125 SEBONIC RD
SOUTH HAMPTON NY
11955
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 TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. WALTER W STOCKTON
Title or Position: C.E.O.
Credential:
Phone: 631-878-8900