Provider Demographics
NPI:1811571565
Name:INSTITUTE FOR COMMUNITY LIVING , INC.
Entity Type:Organization
Organization Name:INSTITUTE FOR COMMUNITY LIVING , INC.
Other - Org Name:AS ONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:LYNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:BACCHUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-385-3030
Mailing Address - Street 1:125 BROAD STREET
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10004-2768
Mailing Address - Country:US
Mailing Address - Phone:212-385-3030
Mailing Address - Fax:
Practice Address - Street 1:125 BROAD STREET
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10004-2768
Practice Address - Country:US
Practice Address - Phone:212-385-3030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INSTITUTE FOR COMMUNITY LIVING, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-05-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center