NPIMap

Organization Active NPI

Independent Group Home Living

  • Intellectual Disabilities Intermediate Care Facility
  • Speonk, NY
National Provider Identifier
1801069372
Registry record updated Apr 7, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X
Legal business name
INDEPENDENT GROUP HOME LIVING
Practice address
114 N Phillips Ave
Speonk, NY 11972
Phone
(631) 878-8900
Fax
(631) 878-8201
NPI assigned
Apr 7, 2008
Last updated
Apr 7, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 7, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Walter W Stockton
Title
C.E.O.
Phone
(631) 878-8900

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Nursing Facility/Intermediate Care Facility 313M00000X
Intellectual Disabilities Intermediate Care Facility 315P00000X Primary

Addresses

Primary practice location

114 N Phillips Ave
Speonk, NY 11972

Mailing address

221 N Sunrise Service Rd
Manorville, NY 11949-9604
Phone (631) 878-8900

Other identifiers 1

IdentifierTypeStateIssuer
00945455MedicaidNY

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1801069372. Details of each certification follow.

  • CCN 33G709 Intermediate care facility for individuals with intellectual disabilities · Active · Name & address match · Details

Intermediate care facility for individuals with intellectual disabilities certification: CCN 33G709

Name & address match This certification has no NPI in the Medicare enrollment files. CMS publishes enrollment files for six facility types only, so it was connected to this NPI by matching the name and address CMS publishes for it.

Legal name
INDEPENDENT GROUP HOME LIVING PROGRAM, INC
Certification status
Active
Provider type (POS)
Intermediate care facility for individuals with intellectual disabilities
Participating since
Mar 31, 1986
Last certification
Jan 16, 2025
Beds
12
Ownership / control type
Private (non-profit)
Facility address
114 N Phillips Ave
Speonk, NY 11972

National Provider Directory

National Provider Directory
Tax ID family
Independent Group Home Living21 organizations share this tax ID, including this one

Other organizations with this tax ID 20

Organizations that report the same tax identification number in the National Provider Directory.

View all 20

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1207526400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1207526400000",
    "number": "1801069372",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "221 N SUNRISE SERVICE RD",
            "city": "MANORVILLE",
            "state": "NY",
            "postal_code": "119499604",
            "telephone_number": "631-878-8900",
            "fax_number": "631-878-8201"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "114 N PHILLIPS AVE",
            "city": "SPEONK",
            "state": "NY",
            "postal_code": "11972",
            "telephone_number": "631-878-8900",
            "fax_number": "631-878-8201"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INDEPENDENT GROUP HOME LIVING",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-04-07",
        "last_updated": "2008-04-07",
        "status": "A",
        "authorized_official_last_name": "STOCKTON",
        "authorized_official_first_name": "WALTER",
        "authorized_official_middle_name": "W",
        "authorized_official_title_or_position": "C.E.O.",
        "authorized_official_telephone_number": "631-878-8900",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "313M00000X",
            "taxonomy_group": "",
            "desc": "Nursing Facility/Intermediate Care Facility",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "315P00000X",
            "taxonomy_group": "",
            "desc": "Intermediate Care Facility, Intellectual Disabilities",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00945455",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Speonk, NY

Sources for this page

Verify at the official NPI Registry.