Provider Demographics
NPI:1336431675
Name:C-LINE COMMUNITY OUTREACH SERVICES
Entity Type:Organization
Organization Name:C-LINE COMMUNITY OUTREACH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLINE
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-200-1965
Mailing Address - Street 1:PO BOX 15802
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07305-0802
Mailing Address - Country:US
Mailing Address - Phone:201-200-1965
Mailing Address - Fax:201-200-1826
Practice Address - Street 1:110 MARTIN LUTHER KING JR DR
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07305-3168
Practice Address - Country:US
Practice Address - Phone:201-200-1965
Practice Address - Fax:201-200-1826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-04
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00116800101YA0400X
NJ44SC05375200101YM0800X
NJ2000071261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0352233Medicaid
NJ032809Medicare UPIN