Provider Demographics
NPI:1164132148
Name:FIVIC SUPPORT SERVICES
Entity Type:Organization
Organization Name:FIVIC SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AMA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BAFFOE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-392-0430
Mailing Address - Street 1:209 PASSAIC AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-1960
Mailing Address - Country:US
Mailing Address - Phone:973-392-0430
Mailing Address - Fax:
Practice Address - Street 1:209 PASSAIC AVE
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-1960
Practice Address - Country:US
Practice Address - Phone:973-392-0430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-30
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1946Medicaid