MEDICARE: AVIDD COMMUNITY SERVICES

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255945515
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVIDD COMMUNITY SERVICES

Provider Business Mailing Address
First Line	:	92 BROADWAY
Second Line	:
City	:	DENVILLE
State	:	NJ
Zip	:	07834-2761
Country	:	US
Telephone Number	:	973-664-1770
Fax Number	:

Provider Business Practice Location Address
First Line	:	20 CIRCLE DRIVE
Second Line	:
City	:	MT. TABOR
State	:	NJ
Zip	:	07878
Country	:	US
Telephone Number	:	973-664-1770
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	TERRENCE MCKEON
Credential	:
Telephone Number	:	973-886-1953

Provider Enumeration Date	:	09/03/2020
Last Update Date	:	09/03/2020

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