Provider Demographics
NPI:1396811758
Name:MT. CARMEL GUILD ICMS UNION
Entity type:Organization
Organization Name:MT. CARMEL GUILD ICMS UNION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCLENDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-266-7992
Mailing Address - Street 1:590 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-2522
Mailing Address - Country:US
Mailing Address - Phone:973-266-7992
Mailing Address - Fax:973-596-4057
Practice Address - Street 1:505 SOUTH AVE E
Practice Address - Street 2:
Practice Address - City:CRANFORD
Practice Address - State:NJ
Practice Address - Zip Code:07016-3246
Practice Address - Country:US
Practice Address - Phone:908-497-3923
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7350601Medicaid