=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669465753
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PASCACK COMMUNITY SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 363 OLD HOOK RD
-----------------------------------------------------
City | WESTWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07675-3201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-664-6649
-----------------------------------------------------
Fax | 201-664-5542
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 363 OLD HOOK RD
-----------------------------------------------------
City | WESTWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07675-3201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-664-6649
-----------------------------------------------------
Fax | 201-664-5542
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLER
-----------------------------------------------------
Name | MS. SUSAN SHANNON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 201-664-1842
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0700X
-----------------------------------------------------
Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
-----------------------------------------------------
License Number | 80137
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------