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General NPI Number Information
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NPI Number | 1437945946
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Entity Type | Organization
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Legal Business Name | CLINTON AVENUE COMMUNITY CARE CENTER PC
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Dates
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Enumeration Date | 04/19/2025
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Last Update Date | 04/19/2025
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Provider Practice Location Address
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Address Line | 1577 ROUTE 517
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City | HACKETTSTOWN
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State | NJ
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Zip | 07840-2708
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Country | US
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Telephone | 973-672-8573
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Fax |
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Provider Business Mailing Address
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Address Line | 613 PARK AVE
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City | EAST ORANGE
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State | NJ
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Zip | 07017-1905
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Country | US
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Telephone | 973-672-2455
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Fax | 973-675-0040
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Authorized Official
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Title or Position | CHIEF REVENUE OFFICER & VBC
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Name | LUZ CAPCHA
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Credential |
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Telephone | 973-672-2455
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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