Basic Information
| Provider Information | |||||||||
| NPI: | 1023475134 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY CLINICAL SERVICES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CCS PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 95000 LBX 7660 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191950001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077778202 | ||||||||
| FaxNumber: | 2077836660 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 SABATTUS ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | LEWISTON | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042405553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077553160 | ||||||||
| FaxNumber: | 2077553166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2016 | ||||||||
| LastUpdateDate: | 10/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | ELIAS | ||||||||
| AuthorizedOfficialFirstName: | COLEEN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/CFO | ||||||||
| AuthorizedOfficialTelephone: | 2075133897 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY CLINICAL SERVICES, INC. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.