Provider Demographics
NPI:1578612479
Name:CANDLELIGHT MEDICAL
Entity Type:Organization
Organization Name:CANDLELIGHT MEDICAL
Other - Org Name:CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KINNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-353-8813
Mailing Address - Street 1:195 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-3921
Mailing Address - Country:US
Mailing Address - Phone:973-353-8813
Mailing Address - Fax:973-353-8815
Practice Address - Street 1:195 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-3921
Practice Address - Country:US
Practice Address - Phone:973-353-8813
Practice Address - Fax:973-353-8815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02378100170100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical GeneticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8848254Medicaid
NJ0079871Medicaid