MEDICARE: ELWYN NEW JERSEY

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	:	1841726866
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELWYN NEW JERSEY

Provider Business Mailing Address
First Line	:	228 W LANDIS AVE BLDG C
Second Line	:
City	:	VINELAND
State	:	NJ
Zip	:	08360-8138
Country	:	US
Telephone Number	:	856-794-5300
Fax Number	:

Provider Business Practice Location Address
First Line	:	15TH & SO JERSEY AVE
Second Line	:
City	:	DOROTHY
State	:	NJ
Zip	:	08317
Country	:	US
Telephone Number	:	609-476-4399
Fax Number	:	609-909-3872

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. WILLIAM HARTLEY
Credential	:
Telephone Number	:	856-794-5300

Provider Enumeration Date	:	05/11/2017
Last Update Date	:	08/12/2022

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