Provider Demographics
NPI:1689913196
Name:KEYSTONE INDEPENDENT LIVING
Entity Type:Organization
Organization Name:KEYSTONE INDEPENDENT LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:FLEESE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-702-8104
Mailing Address - Street 1:100 ABINGTON EXECUTIVE PARK
Mailing Address - Street 2:SUITE B
Mailing Address - City:CLARKS SUMMIT
Mailing Address - State:PA
Mailing Address - Zip Code:18411-2260
Mailing Address - Country:US
Mailing Address - Phone:570-702-8000
Mailing Address - Fax:
Practice Address - Street 1:202 BOULEVARD AVE
Practice Address - Street 2:
Practice Address - City:PECKVILLE
Practice Address - State:PA
Practice Address - Zip Code:18452-1002
Practice Address - Country:US
Practice Address - Phone:570-307-4067
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-04
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA226650311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home