Organization
INDEPENDENT GROUP HOME LIVING
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. WALTER W. STOCKTON (CHIEF EXECUTIVE OFFICER)
(631) 878-8900
Entity
Organization
Contact information
Practice address
21 MONTAUK HIGHWAY, CENTER MORICHES, NY 11934
(631) 878-8900
(631) 878-8900
Mailing address
221 N SUNRISE SERVICE RD, MANORVILLE, NY 11949-9604
(631) 878-8900
(631) 878-8900
Taxonomy
Speciality
Code
Description
License number
State
313M00000X
Nursing Facility/Intermediate Care Facility
—
—
315P00000X
Intellectual Disabilities Intermediate Care Facility
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00575159
—
NY
Enumeration date
04/07/2008
Last updated
04/07/2008
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