Healthcare Provider Details

I. General information

NPI: 1629675012
Provider Name (Legal Business Name): 8530 TOWNSHIP LINE ROAD OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2020
Last Update Date: 03/23/2025
Certification Date: 03/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8530 TOWNSHIP LINE RD
INDIANAPOLIS IN
46260-1927
US

IV. Provider business mailing address

2701 RENAISSANCE BLVD FL 4
KING OF PRUSSIA PA
19406-2781
US

V. Phone/Fax

Practice location:
  • Phone: 463-999-9045
  • Fax:
Mailing address:
  • Phone: 610-994-2968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: SERGIO CRUZ
Title or Position: CFO
Credential:
Phone: 610-427-9434