Provider Demographics
NPI:1578168712
Name:INDY DEVELOPMENTAL RESIDENTIAL SERVICE LLC
Entity Type:Organization
Organization Name:INDY DEVELOPMENTAL RESIDENTIAL SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-970-3880
Mailing Address - Street 1:1121 N RURAL ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46201-1328
Mailing Address - Country:US
Mailing Address - Phone:317-970-3880
Mailing Address - Fax:
Practice Address - Street 1:1121 N RURAL ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46201-1328
Practice Address - Country:US
Practice Address - Phone:317-970-3880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services