Provider Demographics
NPI:1114331857
Name:DEVELOPMENTAL DISABILITIES INSTITUTE
Entity Type:Organization
Organization Name:DEVELOPMENTAL DISABILITIES INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SOPHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUEL
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:631-366-2960
Mailing Address - Street 1:99 HOLLYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3135
Mailing Address - Country:US
Mailing Address - Phone:631-366-2960
Mailing Address - Fax:631-366-5873
Practice Address - Street 1:25 LITTLE PLAINS RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-4550
Practice Address - Country:US
Practice Address - Phone:631-366-2969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6917319315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6917319OtherOPERATING CERTFICATE