MEDICARE: PRINCE ASSOCIATION FOR THE DEVELOPMENTALLY DISABLED, INC.

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

General Provider Information

NPI Number	:	1265828396
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRINCE ASSOCIATION FOR THE DEVELOPMENTALLY DISABLED, INC.

Provider Business Mailing Address
First Line	:	20 TWISTING LN
Second Line	:
City	:	WILLINGBORO
State	:	NJ
Zip	:	08046-4116
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	106 N GARDEN BLVD
Second Line	:
City	:	EDGEWATER PARK
State	:	NJ
Zip	:	08010-2147
Country	:	US
Telephone Number	:	609-877-6920
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	WILLA PRINCE
Credential	:
Telephone Number	:	609-877-6745

Provider Enumeration Date	:	04/15/2015
Last Update Date	:	11/15/2016

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