Provider Demographics
NPI:1861622128
Name:NORTHEAST INDEPENDENT LIVING SERVICES
Entity type:Organization
Organization Name:NORTHEAST INDEPENDENT LIVING SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PAYROLL BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:FORTNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-221-8282
Mailing Address - Street 1:909 BROADWAY
Mailing Address - Street 2:SUITE 350
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-4249
Mailing Address - Country:US
Mailing Address - Phone:573-221-8282
Mailing Address - Fax:573-221-8233
Practice Address - Street 1:909 BROADWAY
Practice Address - Street 2:SUITE 350
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-4249
Practice Address - Country:US
Practice Address - Phone:573-221-8282
Practice Address - Fax:573-221-8233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-21
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO834251T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization