Provider Demographics
NPI:1205378130
Name:INDEPENDENT GROUP HOME LIVING PROGRAM, INC
Entity Type:Organization
Organization Name:INDEPENDENT GROUP HOME LIVING PROGRAM, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARY BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:LICHTNEGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-878-8900
Mailing Address - Street 1:221 N SUNRISE SERVICE RD
Mailing Address - Street 2:
Mailing Address - City:MANORVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11949-9604
Mailing Address - Country:US
Mailing Address - Phone:631-878-8900
Mailing Address - Fax:631-878-8201
Practice Address - Street 1:914 RAINBOW COMMONS
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747
Practice Address - Country:US
Practice Address - Phone:631-878-8900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-09
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility