Basic Information
| Provider Information | |||||||||
| NPI: | 1063574135 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLACKSTONE VALLEY COMMUNITY HEALTH CARE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 42 PARK PL | ||||||||
| Address2: | |||||||||
| City: | PAWTUCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028604010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017290080 | ||||||||
| FaxNumber: | 4017290438 | ||||||||
| Practice Location | |||||||||
| Address1: | 42 PARK PL | ||||||||
| Address2: | |||||||||
| City: | PAWTUCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028604010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017290080 | ||||||||
| FaxNumber: | 4017290438 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2006 | ||||||||
| LastUpdateDate: | 03/06/2012 | ||||||||
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| AuthorizedOfficialLastName: | LAVOIE | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4017290080 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | ACF01536 | RI | N | Agencies | Community/Behavioral Health | 261QF0400X | ACF01536 | RI | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | BV01759 | 05 | RI | MEDICAID |