Provider Demographics
NPI:1669465753
Name:PASCACK COMMUNITY SERVICES
Entity Type:Organization
Organization Name:PASCACK COMMUNITY SERVICES
Other - Org Name:LILLIAN BOOTH DIALYSIS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-664-1842
Mailing Address - Street 1:363 OLD HOOK RD
Mailing Address - Street 2:
Mailing Address - City:WESTWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-3201
Mailing Address - Country:US
Mailing Address - Phone:201-664-6649
Mailing Address - Fax:201-664-5542
Practice Address - Street 1:363 OLD HOOK RD
Practice Address - Street 2:
Practice Address - City:WESTWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07675-3201
Practice Address - Country:US
Practice Address - Phone:201-664-6649
Practice Address - Fax:201-664-5542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ80137261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ91068OtherAMERICHOICE
NJIL00996OtherHEALTHNET
NJ2020133OtherAETNA
NJH478876OtherOXFORD
NY01560030Medicaid
NY009552OtherEMPIRE
NJ6585701Medicaid
NJIL00996OtherHEALTHNET