Provider Demographics
NPI:1447062013
Name:KEYSTONE COMMUNITY LIVING, INC
Entity type:Organization
Organization Name:KEYSTONE COMMUNITY LIVING, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:FANTUZZI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
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:
Practice Address - Street 1:114 ADAMS ST
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-7010
Practice Address - Country:US
Practice Address - Phone:908-757-1080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities