Healthcare Provider Details

I. General information

NPI: 1730929050
Provider Name (Legal Business Name): FOUR CORNERS COMMUNITY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2024
Last Update Date: 05/27/2024
Certification Date: 05/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 19TH ST FL 1
UNION CITY NJ
07087-5439
US

IV. Provider business mailing address

209 PASSAIC AVE
BELLEVILLE NJ
07109-1960
US

V. Phone/Fax

Practice location:
  • Phone: 973-210-6066
  • Fax:
Mailing address:
  • Phone: 973-392-0430
  • Fax: 973-436-4714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MISS AMA J BAFFOE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 973-210-6066