1669465753 NPI number — PASCACK COMMUNITY SERVICES

Table of content: (NPI 1669465753)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669465753 NPI number — PASCACK COMMUNITY SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PASCACK COMMUNITY SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LILLIAN BOOTH DIALYSIS CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669465753
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
363 OLD HOOK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTWOOD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07675-3201
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-664-6649
Provider Business Mailing Address Fax Number:
201-664-5542

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
363 OLD HOOK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTWOOD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07675-3201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-664-6649
Provider Business Practice Location Address Fax Number:
201-664-5542
Provider Enumeration Date:
08/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SHANNON
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLER
Authorized Official Telephone Number:
201-664-1842

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X , with the licence number:  80137 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 91068 . This is a "AMERICHOICE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: IL00996 . This is a "HEALTHNET" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 2020133 . This is a "AETNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: H478876 . This is a "OXFORD" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 01560030 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 009552 . This is a "EMPIRE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 6585701 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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