Healthcare Provider Details

I. General information

NPI: 1063432672
Provider Name (Legal Business Name): CORAM ALTERNATE SITE SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 03/07/2023
Certification Date: 12/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 PASSAIC AVE
FAIRFIELD NJ
07004-3516
US

IV. Provider business mailing address

PO BOX 809160
CHICAGO IL
60680-9160
US

V. Phone/Fax

Practice location:
  • Phone: 973-756-5963
  • Fax:
Mailing address:
  • Phone: 303-672-8631
  • Fax: 303-298-0047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberHP0218401
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License NumberHP0218401
License Number StateNJ

VIII. Authorized Official

Name: TRICIA LACAVICH
Title or Position: PRESIDENT
Credential:
Phone: 314-306-3255