Provider Demographics
NPI:1871771048
Name:CENTER FOR INDEPENDENT LIVING INC
Entity type:Organization
Organization Name:CENTER FOR INDEPENDENT LIVING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADM
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:IACONA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-460-2108
Mailing Address - Street 1:4700 BUCHANAN DR
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-7108
Mailing Address - Country:US
Mailing Address - Phone:772-460-2108
Mailing Address - Fax:772-466-0969
Practice Address - Street 1:4700 BUCHANAN DR
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-7108
Practice Address - Country:US
Practice Address - Phone:772-460-2108
Practice Address - Fax:772-466-0969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-09
Last Update Date:2008-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10026310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility