Provider Demographics
NPI:1659898120
Name:AMERICAN COMMUNITY CLINICAL OUTREACH CENTERS
Entity Type:Organization
Organization Name:AMERICAN COMMUNITY CLINICAL OUTREACH CENTERS
Other - Org Name:AMECCO-USA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CANDRICK
Authorized Official - Middle Name:C
Authorized Official - Last Name:DARKASHADE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:848-467-1409
Mailing Address - Street 1:610 FOREST VIEW DR
Mailing Address - Street 2:
Mailing Address - City:AVENEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07001-2176
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:285 ROSEVILLE AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-1703
Practice Address - Country:US
Practice Address - Phone:973-481-2200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-25
Last Update Date:2017-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ173-040103TA0400X, 251S00000X, 252Y00000X, 261QD1600X, 261QM0801X, 261QM0855X
NJ173-404261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
No252Y00000XAgenciesEarly Intervention Provider Agency
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health