MEDICARE: ATLANTIC FAMILY WELLNESS 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	101YA0400X	Addiction (Substance Use Disorder) Counselor	37LC00119700	NJ

General Provider Information

NPI Number	:	1053746461
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATLANTIC FAMILY WELLNESS CENTER LLC

Provider Business Mailing Address
First Line	:	267 CYPRESS DR
Second Line	:
City	:	BAYVILLE
State	:	NJ
Zip	:	08721-3110
Country	:	US
Telephone Number	:	732-801-4505
Fax Number	:	732-269-8385

Provider Business Practice Location Address
First Line	:	222 SERPENTINE DR
Second Line	:
City	:	BAYVILLE
State	:	NJ
Zip	:	08721-3227
Country	:	US
Telephone Number	:	732-801-4505
Fax Number	:	732-269-8385

Authorized Official
Title or Position	:	CEO
Name	:	DR. BETTY JARUSIEWICZ
Credential	:	PHD
Telephone Number	:	732-801-4505

Provider Enumeration Date	:	09/05/2013
Last Update Date	:	09/05/2013

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