Healthcare Provider Details

I. General information

NPI: 1073802013
Provider Name (Legal Business Name): SUPPORT FOR INDEPENDENT LIVING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2011
Last Update Date: 08/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 HAVERFORD RD SUITE 220
ARDMORE PA
19003-2913
US

IV. Provider business mailing address

2320 HAVERFORD RD SUITE 220
ARDMORE PA
19003-2913
US

V. Phone/Fax

Practice location:
  • Phone: 610-649-3148
  • Fax: 610-649-3148
Mailing address:
  • Phone: 610-649-3148
  • Fax: 610-649-3923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: DAISY ANGLIN
Title or Position: EXECUTIVE DIRECTOR
Credential: MBA
Phone: 610-649-3148