MEDICARE: DEDICATED GROUP HOMES

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	103K00000X	Behavior Analyst		DE

General Provider Information

NPI Number	:	1437501905
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEDICATED GROUP HOMES

Provider Business Mailing Address
First Line	:	180 ALYSSA DR
Second Line	:
City	:	MOUNT ROYAL
State	:	NJ
Zip	:	08061-1071
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	180 ALYSSA DR
Second Line	:
City	:	MOUNT ROYAL
State	:	NJ
Zip	:	08061-1071
Country	:	US
Telephone Number	:	866-625-9934
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ELIENNE DAUTRUCHE
Credential	:
Telephone Number	:	856-625-9934

Provider Enumeration Date	:	07/08/2016
Last Update Date	:	07/08/2016

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