MEDICARE: GASTON ACHIDI BOMA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	253Z00000X	In Home Supportive Care Agency
2	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
3	251S00000X	Community/Behavioral Health Agency
4	385HR2060X	Child Intellectual and/or Developmental Disabilities Respite Care
5	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1316592090
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GASTON ACHIDI BOMA

Provider Business Mailing Address
First Line	:	2201 S CLINTON AVE STE 2F
Second Line	:
City	:	SOUTH PLAINFIELD
State	:	NJ
Zip	:	07080-1473
Country	:	US
Telephone Number	:	908-462-4361
Fax Number	:

Provider Business Practice Location Address
First Line	:	2201 S CLINTON AVE STE 2F
Second Line	:
City	:	SOUTH PLAINFIELD
State	:	NJ
Zip	:	07080-1473
Country	:	US
Telephone Number	:	908-462-4361
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2019
Last Update Date	:	08/08/2019

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Directions to “ GASTON ACHIDI BOMA ” Practice Location

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