Basic Information
| Provider Information | |||||||||
| NPI: | 1104859313 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KINSTON COMMUNITY HEALTH CENTER, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2278 | ||||||||
| Address2: | |||||||||
| City: | KINSTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285022278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2525229800 | ||||||||
| FaxNumber: | 2525229854 | ||||||||
| Practice Location | |||||||||
| Address1: | 324 N QUEEN STREET | ||||||||
| Address2: | |||||||||
| City: | KINSTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285014932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2525229800 | ||||||||
| FaxNumber: | 2525239790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
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| AuthorizedOfficialLastName: | WALLACE | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | LISA | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2525229800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 344575 | 05 | NC | MEDICAID |