Basic Information
| Provider Information | |||||||||
| NPI: | 1003585506 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THREE LOWER COUNTIES COMMUNITY SERVICES INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CHESAPEAKE HEALTH CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1978 | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218021978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107491015 | ||||||||
| FaxNumber: | 4107490654 | ||||||||
| Practice Location | |||||||||
| Address1: | 10902 OLD PRINCESS ANNE RD | ||||||||
| Address2: | |||||||||
| City: | PRINCESS ANNE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218532940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107491015 | ||||||||
| FaxNumber: | 4107490654 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2021 | ||||||||
| LastUpdateDate: | 09/28/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOLLAND | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4107491015 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 119591300 | 05 | MD | MEDICAID |