MEDICARE: BROADWAY GROUP HOME 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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1720794274
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROADWAY GROUP HOME LLC

Provider Business Mailing Address
First Line	:	17-17 BROADWAY
Second Line	:
City	:	FAIR LAWN
State	:	NJ
Zip	:	07410-2055
Country	:	US
Telephone Number	:	201-703-3980
Fax Number	:

Provider Business Practice Location Address
First Line	:	20 LOWER MATCHAPONIX AVE
Second Line	:
City	:	MONROE
State	:	NJ
Zip	:	08831-1424
Country	:	US
Telephone Number	:	973-546-0488
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	PATRICK PATTON
Credential	:
Telephone Number	:	973-546-0488

Provider Enumeration Date	:	01/27/2023
Last Update Date	:	01/27/2023

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