Healthcare Provider Details

I. General information

NPI: 1942810551
Provider Name (Legal Business Name): AVENUES RECOVERY CENTER OF FORT WAYNE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2020
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2626 FAIRFIELD AVE
FORT WAYNE IN
46807-1215
US

IV. Provider business mailing address

211 BOULEVARD OF THE AMERICAS, SUITE 503
LAKEWOOD NJ
08701
US

V. Phone/Fax

Practice location:
  • Phone: 260-235-5900
  • Fax:
Mailing address:
  • Phone: 732-967-2635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: HUDI ALTER
Title or Position: CEO
Credential:
Phone: 732-967-2635