1215987771 NPI number — ATLANTICARE HEALTH SERVICES, INC.

Table of content: MRS. JOHNETTE OWENS (NPI 1538100219)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215987771 NPI number — ATLANTICARE HEALTH SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ATLANTICARE HEALTH SERVICES, INC.
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:
ATLANTICARE HEALTH SERVICES - MISSION HEALTHCARE
Provider Other Organization Name Type Code:
5
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:
1215987771
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
65 W JIMMIE LEEDS RD
Provider Second Line Business Mailing Address:
ATTN FINANCE J HOKE
Provider Business Mailing Address City Name:
POMONA
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-569-7303
Provider Business Mailing Address Fax Number:
609-272-6251

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2009 BACHARACH BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTIC CITY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-344-5714
Provider Business Practice Location Address Fax Number:
609-345-0775
Provider Enumeration Date:
05/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FESTA
Authorized Official First Name:
SANDY
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR FQHC
Authorized Official Telephone Number:
609-572-6051

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  23265 , 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: 31D103000 . This is a "CMS-CLIA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0028592 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 60019117 . This is a "HORIZON HEALTH HMO" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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