Provider Demographics
NPI:1164913786
Name:THE PASSION CARE CENTER
Entity Type:Organization
Organization Name:THE PASSION CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-909-8264
Mailing Address - Street 1:187 FAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:PERTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08861-4140
Mailing Address - Country:US
Mailing Address - Phone:267-909-8264
Mailing Address - Fax:215-525-0272
Practice Address - Street 1:187 FAYETTE ST
Practice Address - Street 2:
Practice Address - City:PERTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08861-4140
Practice Address - Country:US
Practice Address - Phone:267-909-8264
Practice Address - Fax:215-525-0272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ101YP2500X
2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0398012Medicaid