Healthcare Provider Details

I. General information

NPI: 1295423648
Provider Name (Legal Business Name): AVIE IDA'S ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2023
Last Update Date: 04/25/2023
Certification Date: 04/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CARRIE PLACE
SICKLERVILLE NJ
08081
US

IV. Provider business mailing address

1 CARRIE PLACE
SICKLERVILLE NJ
08081
US

V. Phone/Fax

Practice location:
  • Phone: 215-380-5441
  • Fax:
Mailing address:
  • Phone: 215-380-5441
  • 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 Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. JESSICA KATHLINE COURSEY
Title or Position: OWNER
Credential:
Phone: 267-216-7239