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General NPI Number Information
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NPI Number | 1093991234
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Entity Type | Organization
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Legal Business Name | INDEPENDENT LIVING GROUP HOME, LLC
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Dates
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Enumeration Date | 01/17/2008
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Last Update Date | 11/18/2019
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Provider Practice Location Address
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Address Line | 924 CLOISTER DR
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City | WINSTON SALEM
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State | NC
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Zip | 27127
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Country | US
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Telephone | 336-767-4540
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Fax | 336-283-9288
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Provider Business Mailing Address
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Address Line | 7748 N POINT BLVD
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City | WINSTON SALEM
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State | NC
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Zip | 27106-3310
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Country | US
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Telephone | 336-767-4540
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Fax | 336-499-0651
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Authorized Official
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Title or Position | DIRECTOR/ OWNER
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Name | SHANITA LOVELACE
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Credential | RN
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Telephone | 336-767-4540
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | 034-224
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License Number State | NC
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Taxonomy #3
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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