Provider Demographics
NPI:1043700495
Name:ATLANTICARE HEALTH SERVICES INC.
Entity Type:Organization
Organization Name:ATLANTICARE HEALTH SERVICES INC.
Other - Org Name:ATLANTICARE MISSION HEALTH CARE GALLOWAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXEC DIR FQHC
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:FESTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-572-6051
Mailing Address - Street 1:1401 ATLANTIC AVE STE 1125
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08401-7001
Mailing Address - Country:US
Mailing Address - Phone:609-572-6051
Mailing Address - Fax:609-572-6001
Practice Address - Street 1:54 W JIMMIE LEEDS RD
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-9438
Practice Address - Country:US
Practice Address - Phone:609-404-7300
Practice Address - Fax:609-572-6008
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ATLANTICARE HEALTH SERVICES INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-11
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ261Q00000X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0028592Medicaid