Provider Demographics
NPI:1730929050
Name:FOUR CORNERS COMMUNITY SERVICES LLC
Entity type:Organization
Organization Name:FOUR CORNERS COMMUNITY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:AMA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BAFFOE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-210-6066
Mailing Address - Street 1:209 PASSAIC AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-1960
Mailing Address - Country:US
Mailing Address - Phone:973-392-0430
Mailing Address - Fax:973-436-4714
Practice Address - Street 1:201 19TH ST FL 1
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:NJ
Practice Address - Zip Code:07087-5439
Practice Address - Country:US
Practice Address - Phone:973-210-6066
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOUR CORNERS COMMUNITY SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-05-27
Last Update Date:2024-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No251X00000XAgenciesSupports Brokerage
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities