Healthcare Provider Details

I. General information

NPI: 1679992929
Provider Name (Legal Business Name): PRIME HEALTHCARE SERVICES - ST. MARY'S PASSAIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2014
Last Update Date: 04/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 MAIN AVE
PASSAIC NJ
07055-5700
US

IV. Provider business mailing address

3300 E GUASTI RD THIRD FLOOR
ONTARIO CA
91761-8655
US

V. Phone/Fax

Practice location:
  • Phone: 973-365-3012
  • Fax:
Mailing address:
  • Phone: 909-235-4311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: TROY A. SCHELL
Title or Position: SECRETARY, GENERAL COUNSEL
Credential: ESQ.
Phone: 909-235-4311