| Organization Name: | INDEPENDENT LIVING GROUP HOME, LLC |
| NPI Number: | 1093991234 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | SHANITA LOVELACE (DIRECTOR/ OWNER) |
| Mailing Address: | 4240 Laurel Ridge Cir Winston Salem |
| State: | NC US |
| Postal Code: | 271073724 |
| Phone Number: | 3367884199 |
| Fax Number: | 3367716297 |
| NPI Enumeration Date: | 01/17/2008 |
| NPI Last Update Date: | 01/17/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 320600000X |
| License Number: | 034-224 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NC |
| Taxonomy Type: | Residential Treatment Facilities |
| Taxonomy Classification: | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A residential facility that provides habilitation services and other care and treatment to adults or children diagnosed with developmental disabilities and/or mental retardation and are not able to live independently. |