# KHALEIDOSCOPE HEALTH CARE INC.

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Parkside Medical Center
- **Organization subpart:** No

## Provider details

- **NPI number:** 1336350909
- **Authorized official:** MR. LARRY M BLAKE LCSW (CEO)
- **Authorized official phone:** (201) 451-5425

## Contact information

- **Practice address:** 75 HARRISON AVENUE, JERSEY CITY, NJ 07304-0070
- **Practice address phone:** (201) 451-5425
- **Practice address fax:** (201) 451-7499
- **Mailing address:** P.O. BOX 4070, 75 HARRISON AVENUE, JERSEY CITY, NJ 07304-0070
- **Mailing address phone:** (201) 451-5425
- **Mailing address fax:** (201) 451-7499

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 101YA0400X | Addiction (Substance Use Disorder) Counselor | — | NJ | — |
| 1041C0700X | Clinical Social Worker | — | NJ | — |
| 1223G0001X | General Practice Dentistry | — | NJ | Yes |
| 133NN1002X | Nutrition Education Nutritionist | — | NJ | — |
| 133V00000X | Registered Dietitian | — | NJ | — |
| 2084P0800X | Psychiatry Physician | — | NJ | — |
| 261QM1300X | Multi-Specialty Clinic/Center | — | NJ | — |
| 261QM2800X | Methadone Clinic | 22613 | NJ | — |

## Other

- **Enumeration date:** 05/25/2007
- **Last updated:** 10/06/2023

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 6103201 | — | NJ |
| 05 | — | 7734301 | — | NJ |
| 05 | — | 7864108 | — | NJ |