Provider Demographics
NPI:1912388349
Name:KEYSTONE COMMUNITY LIVING, INC.
Entity Type:Organization
Organization Name:KEYSTONE COMMUNITY LIVING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAY
Authorized Official - Middle Name:
Authorized Official - Last Name:FANTUZZI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-757-1080
Mailing Address - Street 1:154 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH PLAINFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07080-3402
Mailing Address - Country:US
Mailing Address - Phone:908-757-1080
Mailing Address - Fax:908-755-6810
Practice Address - Street 1:13 COLTON RD
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08817-4040
Practice Address - Country:US
Practice Address - Phone:908-757-1080
Practice Address - Fax:908-755-6810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-11
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities