Provider Demographics
NPI:1760568802
Name:CIDNY-INDEPENDENT LIVING SERVICES
Entity Type:Organization
Organization Name:CIDNY-INDEPENDENT LIVING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-254-5000
Mailing Address - Street 1:PO BOX 180032
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-0032
Mailing Address - Country:US
Mailing Address - Phone:212-254-5000
Mailing Address - Fax:212-460-9194
Practice Address - Street 1:150 OCEAN PKWY
Practice Address - Street 2:ROOM 101
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-2481
Practice Address - Country:US
Practice Address - Phone:212-254-5000
Practice Address - Fax:212-460-9194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0637L002251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00925306Medicaid