Provider Demographics
NPI:1548433006
Name:INDEPENDENT GROUP HOME LIVING
Entity Type:Organization
Organization Name:INDEPENDENT GROUP HOME LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:W
Authorized Official - Last Name:STOCKTON
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 1:535 MOUTAUK HIGHWAY
Practice Address - Street 2:
Practice Address - City:EASTPORT
Practice Address - State:NY
Practice Address - Zip Code:11941
Practice Address - Country:US
Practice Address - Phone:631-878-8900
Practice Address - Fax:631-878-8201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01118776Medicaid