Provider Demographics
NPI:1720145410
Name:PRINCETON/CORNER HOUSE
Entity Type:Organization
Organization Name:PRINCETON/CORNER HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:DE BLASIO
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CEAP
Authorized Official - Phone:609-924-8018
Mailing Address - Street 1:1 MONUMENT DR
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08540-3036
Mailing Address - Country:US
Mailing Address - Phone:609-924-8018
Mailing Address - Fax:609-699-2045
Practice Address - Street 1:1 MONUMENT DR
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08540-3406
Practice Address - Country:US
Practice Address - Phone:609-924-8018
Practice Address - Fax:609-688-2045
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRINCETON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-02
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41140261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0540358Medicaid
NJ0100200Medicaid