MEDICARE: AMBERARK HAVEN RESIDENCE

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	:	1598518334
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMBERARK HAVEN RESIDENCE

Provider Business Mailing Address
First Line	:	216 SCOFIELD AVE
Second Line	:
City	:	BRIDGEPORT
State	:	CT
Zip	:	06605-2928
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4218 PARKWOOD DR
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78218-5024
Country	:	US
Telephone Number	:	210-640-4488
Fax Number	:

Authorized Official
Title or Position	:	ONWER
Name	:	MAUREEN ALEXANDER
Credential	:
Telephone Number	:	646-591-5143

Provider Enumeration Date	:	04/10/2024
Last Update Date	:	04/10/2024

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