Healthcare Provider Details

I. General information

NPI: 1932798436
Provider Name (Legal Business Name): IRONBOUND COMMUNITY HEALTH CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2021
Last Update Date: 07/13/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

788 MOUNT PROSPECT AVE FL 2
NEWARK NJ
07104-3221
US

IV. Provider business mailing address

788 MOUNT PROSPECT AVE FL 2
NEWARK NJ
07104-3221
US

V. Phone/Fax

Practice location:
  • Phone: 973-433-9773
  • Fax:
Mailing address:
  • Phone: 973-433-9773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE LOLO
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 908-514-1895