MEDICARE: AVENUES RECOVERY CENTER OF FORT WAYNE, LLC

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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1689532475
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVENUES RECOVERY CENTER OF FORT WAYNE, LLC

Provider Business Mailing Address
First Line	:	211 BOULEVARD OF THE AMERICAS
Second Line	:	SUITE 503
City	:	LAKEWOOD
State	:	NJ
Zip	:	08701
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2626 FAIRFIELD AVE
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46807-1215
Country	:	US
Telephone Number	:	732-967-2635
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	HUDI ALTER
Credential	:
Telephone Number	:	732-967-2635

Provider Enumeration Date	:	01/12/2026
Last Update Date	:	01/12/2026

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