Provider Demographics
NPI:1164646527
Name:ADEC - MIDDLEBURY MEN
Entity Type:Organization
Organization Name:ADEC - MIDDLEBURY MEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHIVELY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-848-7451
Mailing Address - Street 1:19670 SR 120
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:IN
Mailing Address - Zip Code:46507-0398
Mailing Address - Country:US
Mailing Address - Phone:574-848-7451
Mailing Address - Fax:574-848-5917
Practice Address - Street 1:603 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:IN
Practice Address - Zip Code:46540-9568
Practice Address - Country:US
Practice Address - Phone:574-848-7451
Practice Address - Fax:574-848-5917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN2670I0010JN06320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities