Basic Information
| Provider Information | |||||||||
| NPI: | 1114175916 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHARLES RIVER COMMUNITY HEALTH, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | JOSEPH M. SMITH COMMUNITY HEALTH CENTER, INC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 495 WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021351007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177830500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 495 WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021351007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177830500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2008 | ||||||||
| LastUpdateDate: | 03/07/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GIANCI | ||||||||
| AuthorizedOfficialFirstName: | CHRISTEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 6178707431 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 | 110024306G | 05 | MA | MEDICAID |