Provider Demographics
NPI:1952426496
Name:NORTHEAST INDEPENDENT LIVING SERVICES
Entity Type:Organization
Organization Name:NORTHEAST INDEPENDENT LIVING SERVICES
Other - Org Name:NEILS
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:
Authorized Official - Last Name:KENDRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-221-8282
Mailing Address - Street 1:4500 PARIS GRAVEL RD
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-5422
Mailing Address - Country:US
Mailing Address - Phone:573-221-8282
Mailing Address - Fax:573-221-9445
Practice Address - Street 1:4500 PARIS GRAVEL RD
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-5422
Practice Address - Country:US
Practice Address - Phone:573-221-8282
Practice Address - Fax:573-221-8233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
No251J00000XAgenciesNursing CareGroup - Single Specialty
No251X00000XAgenciesSupports Brokerage
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO266213701Medicaid