MEDICARE: PRINCETON DETOX AND RECOVERY CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1740749357
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRINCETON DETOX AND RECOVERY CENTER, LLC

Provider Business Mailing Address
First Line	:	4287 US HIGHWAY 1
Second Line	:
City	:	MONMOUTH JUNCTION
State	:	NJ
Zip	:	08852-1902
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4287 US HIGHWAY 1
Second Line	:
City	:	MONMOUTH JUNCTION
State	:	NJ
Zip	:	08852-1902
Country	:	US
Telephone Number	:	833-653-3869
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE
Name	:	MIKE ROCKS
Credential	:
Telephone Number	:	833-653-3869

Provider Enumeration Date	:	03/14/2019
Last Update Date	:	03/14/2019

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