Provider Demographics
NPI:1376893941
Name:ACTIVITIES OF DAILY LIVING HOME CARE
Entity Type:Organization
Organization Name:ACTIVITIES OF DAILY LIVING HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CNA
Authorized Official - Prefix:
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-394-6639
Mailing Address - Street 1:67 DIANA DR
Mailing Address - Street 2:
Mailing Address - City:MASTIC BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11951-6308
Mailing Address - Country:US
Mailing Address - Phone:631-394-6639
Mailing Address - Fax:
Practice Address - Street 1:67 DIANA DR
Practice Address - Street 2:
Practice Address - City:MASTIC BEACH
Practice Address - State:NY
Practice Address - Zip Code:11951-6308
Practice Address - Country:US
Practice Address - Phone:631-394-6639
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251E00000X, 320700000X, 320800000X, 320900000X, 323P00000X, 347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY32-038829OtherMEDICAID MEDICARE
NY32-038829OtherMEDICAID MEDICARE