State Corporation / Developmental Programs / Profit Partnership Public Service Corporation Sole Proprietorship / Status / Business Corporation / /
Country
United States / /
Currency
USD / / /
Facility
Individual Facility / Building Harrisburg / /
IndustryTerm
individualized client services / medical technology / behavioral health services / community residential services / hospice services / long-term care services / maternity services / healthcare provider applying / home health services / /
Organization
FFS PEP / Long Term Living Bureau of Provider Services / Dept of Health / Prepaid Health Plan Authority / Internal Revenue Service / office of Developmental Programs / Medicare / U.S. Department of Justice / Bureau of Autism Services / Drug Enforcement Agency / Bureau of Quality and Provide / Home Office / POST OFFICE / Bureau of Quality / HealthChoices Supplemental Service / Department of State Corporation Bureau / / /
INSTRUCTIONS FOR COMPLETION OF PENNSYLVANIA PROMISe™ PROVIDER ENROLLMENT BASE APPLICATION Applications must be typed or completed in black ink, or they will not be accepted. Applications will be scanned - please do NOT