Healthcare Provider Details

I. General information

NPI: 1144986811
Provider Name (Legal Business Name): FOUR CORNERS COMMUNITY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2021
Last Update Date: 11/16/2021
Certification Date: 11/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 MOORE ST FL 2
HACKENSACK NJ
07601-7104
US

IV. Provider business mailing address

209 PASSAIC AVE
BELLEVILLE NJ
07109-1960
US

V. Phone/Fax

Practice location:
  • Phone: 973-392-0430
  • Fax:
Mailing address:
  • Phone: 973-392-0430
  • Fax: 973-860-5179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MS. AMA J BAFFOE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 973-392-0430