Provider Demographics
NPI:1699297168
Name:ECHO BLUE ENTERPRISE LLC
Entity type:Organization
Organization Name:ECHO BLUE ENTERPRISE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:KILCOYNE
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:201-759-5141
Mailing Address - Street 1:123 MUNSONHURST RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:NJ
Mailing Address - Zip Code:07416-1812
Mailing Address - Country:US
Mailing Address - Phone:201-759-5141
Mailing Address - Fax:973-625-7107
Practice Address - Street 1:550 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BOONTON
Practice Address - State:NJ
Practice Address - Zip Code:07005-1168
Practice Address - Country:US
Practice Address - Phone:973-570-4271
Practice Address - Fax:973-625-7107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-16
Last Update Date:2017-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00164500363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty