Healthcare Provider Details

I. General information

NPI: 1376103556
Provider Name (Legal Business Name): GAUDENZIA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 06/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18514 PENTECOSTAL ST
ELLENDALE DE
19941-3358
US

IV. Provider business mailing address

106 W MAIN ST
NORRISTOWN PA
19401-4716
US

V. Phone/Fax

Practice location:
  • Phone: 302-836-8260
  • Fax: 302-503-3155
Mailing address:
  • Phone: 610-239-9600
  • Fax: 610-275-7025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. NICHOLAS CHABAN
Title or Position: CONTROLLER
Credential: CPA
Phone: 610-239-9600