Basic Information
| Provider Information | |||||||||
| NPI: | 1093044331 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY ACTION COMMITTEE OF PIKE COUNTY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 941 MARKET ST | ||||||||
| Address2: | |||||||||
| City: | PIKETON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456619757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402892371 | ||||||||
| FaxNumber: | 7402893545 | ||||||||
| Practice Location | |||||||||
| Address1: | 717 5TH ST | ||||||||
| Address2: | PORTSMOUTH FAMILY HEALTH CENTER | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456624007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403546605 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2009 | ||||||||
| LastUpdateDate: | 02/12/2013 | ||||||||
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| AuthorizedOfficialLastName: | ROBERTS | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7402892371 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 3051754 | 05 | OH | MEDICAID | 361953 | 01 | CMS FQHC CERTIFICATION NUMBER | OTHER | 1447349956 | 01 | INDIVIDUAL PROVIDERS NPI # | OTHER |