Provider Demographics
NPI:1306969787
Name:KHALEIDOSCOPE HEALTH CARE INC.
Entity type:Organization
Organization Name:KHALEIDOSCOPE HEALTH CARE INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:JR
Authorized Official - Credentials:LCSW
Authorized Official - Phone:201-386-9264
Mailing Address - Street 1:P.O BOX 4070 75 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07304-0070
Mailing Address - Country:US
Mailing Address - Phone:201-451-5425
Mailing Address - Fax:201-451-7499
Practice Address - Street 1:127 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07304-3615
Practice Address - Country:US
Practice Address - Phone:201-451-5425
Practice Address - Fax:201-451-7499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ80305261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7864108Medicaid
NJ6103201Medicaid
NJ6103201Medicaid