Healthcare Provider Details

I. General information

NPI: 1164913786
Provider Name (Legal Business Name): THE PASSION CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2018
Last Update Date: 05/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

187 FAYETTE ST
PERTH AMBOY NJ
08861-4140
US

IV. Provider business mailing address

187 FAYETTE ST
PERTH AMBOY NJ
08861-4140
US

V. Phone/Fax

Practice location:
  • Phone: 267-909-8264
  • Fax: 215-525-0272
Mailing address:
  • Phone: 267-909-8264
  • Fax: 215-525-0272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: OMAR RILEY
Title or Position: ACCOUNT MANAGER
Credential:
Phone: 267-909-8264