Provider Demographics
NPI:1528233301
Name:DEVELOPMENTAL DISIABILITIES INSTITUTE
Entity Type:Organization
Organization Name:DEVELOPMENTAL DISIABILITIES INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:A/R MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SOPHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUEL
Authorized Official - Suffix:
Authorized Official - Credentials:
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:631-366-5893
Practice Address - Street 1:73 WADING RIVER HOLLOW RD
Practice Address - Street 2:
Practice Address - City:RIDGE
Practice Address - State:NY
Practice Address - Zip Code:11961-2315
Practice Address - Country:US
Practice Address - Phone:631-366-5876
Practice Address - Fax:631-366-5893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities