Provider Demographics
NPI:1558598052
Name:INSTITUTE FOR COMMUNITY LIVING, INC.
Entity Type:Organization
Organization Name:INSTITUTE FOR COMMUNITY LIVING, INC.
Other - Org Name:CHRONIC ILLNESS DEMONSTRATION PROJECT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DEWEY
Authorized Official - Middle Name:H
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-385-3030
Mailing Address - Street 1:125 BROAD STREET
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10004-2400
Mailing Address - Country:US
Mailing Address - Phone:212-385-3030
Mailing Address - Fax:917-831-4451
Practice Address - Street 1:40 RECTOR ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10006-1705
Practice Address - Country:US
Practice Address - Phone:212-385-3030
Practice Address - Fax:212-385-2380
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INSTITUTE FOR COMMUNITY LIVING, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-11
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7720470A251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01305004Medicaid