=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427198209
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONCERN FOR INDEPENDENT LIVING, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2007
-----------------------------------------------------
Last Update Date | 05/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 312 EXPRESSWAY DRIVE SOUTH
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-750-2225
-----------------------------------------------------
Fax | 631-758-0467
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 358 312 EXPRESSWAY DRIVE SOUTH
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11763
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-758-0474
-----------------------------------------------------
Fax | 631-758-0467
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. RALPH FASANO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 631-758-0474
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 323P00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 7609432
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------