Healthcare Provider Details

I. General information

NPI: 1528197381
Provider Name (Legal Business Name): INDIANA DEVELOPMENTAL TRAINING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11075 N PENNSYLVANIA ST
INDIANAPOLIS IN
46280
US

IV. Provider business mailing address

PO BOX 278
DOUSMAN WI
53118
US

V. Phone/Fax

Practice location:
  • Phone: 317-815-0505
  • Fax: 317-815-1645
Mailing address:
  • Phone: 262-569-5515
  • Fax: 262-569-9962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number StateIN

VIII. Authorized Official

Name: MS. M DEBORAH FRISK
Title or Position: VICE PRESIDENT
Credential: MSW
Phone: 262-569-5515