Healthcare Provider Details

I. General information

NPI: 1114056074
Provider Name (Legal Business Name): INDIANA DEVELOPMENTAL TRAINING CENTER OF LAFAYETTE 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

3700 ROME DRIVE
LAFAYETTE IN
47905
US

IV. Provider business mailing address

PO BOX 278
DOUSMAN WI
53118
US

V. Phone/Fax

Practice location:
  • Phone: 765-448-4220
  • Fax: 765-488-4217
Mailing address:
  • Phone:
  • Fax:

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