Provider Demographics
NPI:1407995137
Name:CENTER FOR INDEPENDENT LIVING OF CENTRAL PA
Entity Type:Organization
Organization Name:CENTER FOR INDEPENDENT LIVING OF CENTRAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:THEOTIS
Authorized Official - Middle Name:W
Authorized Official - Last Name:BRADDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-731-1900
Mailing Address - Street 1:207 HOUSE AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:CAMP HILL
Mailing Address - State:PA
Mailing Address - Zip Code:17011-2308
Mailing Address - Country:US
Mailing Address - Phone:717-731-1900
Mailing Address - Fax:
Practice Address - Street 1:207 HOUSE AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:CAMP HILL
Practice Address - State:PA
Practice Address - Zip Code:17011-2308
Practice Address - Country:US
Practice Address - Phone:717-731-1900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100003963-0010Medicaid
PA100003963-0005Medicaid
PA100003963-0012Medicaid
PA100003963-0008Medicaid