Organization
INDEPENDENT LIVING GROUP HOME, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SHANITA LOVELACE RN (DIRECTOR/ OWNER)
(336) 767-4540
Entity
Organization
Contact information
Practice address
924 CLOISTER DR, WINSTON SALEM, NC 27127
(336) 767-4540
(336) 283-9288
Mailing address
7748 N POINT BLVD, WINSTON SALEM, NC 27106-3310
(336) 767-4540
(336) 499-0651
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
—
—
311ZA0620X
Adult Care Home Facility
—
—
320600000X
Intellectual and/or Developmental Disabilities Residential Treatment Facility
034-224
NC
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
—
—
Other
Enumeration date
01/17/2008
Last updated
11/18/2019
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