Organization
INDEPENDENT SERVICE PROVIDER, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TILAK NIROULA (DIRECTOR)
(717) 882-7892
Entity
Organization
Contact information
Practice address
3544 N PROGRESS AVE STE 205, HARRISBURG, PA 17110-9638
(717) 882-7892
Mailing address
3544 N PROGRESS AVE STE 205, HARRISBURG, PA 17110-9638
(717) 882-7892
Taxonomy
Speciality
Code
Description
License number
State
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
—
—
Other
Enumeration date
09/07/2021
Last updated
09/07/2021
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