=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922217322
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HENDRICKS HOUSE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2007
-----------------------------------------------------
Last Update Date | 08/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 542 N WEST BLVD
-----------------------------------------------------
City | VINELAND
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08360-2847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-794-2443
-----------------------------------------------------
Fax | 856-205-9277
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 542 N. WEST BLVD
-----------------------------------------------------
City | VINELAND
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-794-2443
-----------------------------------------------------
Fax | 856-794-8887
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. AUDREY CARTER
-----------------------------------------------------
Credential | MSM, LCADC
-----------------------------------------------------
Telephone | 856-794-2443
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | 1000007-07
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------