Basic Information
| Provider Information | |||||||||
| NPI: | 1023100955 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY ACTION COMMITTEE OF PIKE COUNTY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAMILY HEALTH CENTER - JACKSON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 941 MARKET ST | ||||||||
| Address2: | |||||||||
| City: | PIKETON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456619757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402892371 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 14590 STATE ROUTE 93 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456408977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402862826 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 06/09/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PITTS | ||||||||
| AuthorizedOfficialFirstName: | KEITH | ||||||||
| AuthorizedOfficialMiddleName: | ERIC | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7402892371 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/09/2020 | ||||||||
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 | 0829465 | 05 | OH | MEDICAID | 2616440 | 05 | OH | MEDICAID |