Healthcare Provider Details

I. General information

NPI: 1902330228
Provider Name (Legal Business Name): 689 SOUTH 16TH STREET CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2017
Last Update Date: 04/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 PASSAIC AVENUE
WEST CALDWELL NJ
07006
US

IV. Provider business mailing address

555 PASSAIC AVENUE
WEST CALDWELL NJ
07006
US

V. Phone/Fax

Practice location:
  • Phone: 973-808-9300
  • Fax:
Mailing address:
  • Phone: 973-808-9300
  • 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 Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: TRICIA MAC EVOY
Title or Position: TRUSTEE
Credential:
Phone: 973-271-5802