Provider Demographics
NPI:1427198209
Name:CONCERN FOR INDEPENDENT LIVING, INC.
Entity Type:Organization
Organization Name:CONCERN FOR INDEPENDENT LIVING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:
Authorized Official - Last Name:FASANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-758-0474
Mailing Address - Street 1:PO BOX 358
Mailing Address - Street 2:312 EXPRESSWAY DRIVE SOUTH
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763
Mailing Address - Country:US
Mailing Address - Phone:631-758-0474
Mailing Address - Fax:631-758-0467
Practice Address - Street 1:312 EXPRESSWAY DRIVE SOUTH
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763
Practice Address - Country:US
Practice Address - Phone:631-750-2225
Practice Address - Fax:631-758-0467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7609432251S00000X
323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility