Basic Information
| Provider Information | |||||||||
| NPI: | 1114913092 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCE COMMUNITY HEALTH, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ADVANCE COMMUNITY HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 ROCK QUARRY RD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276103825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198333111 | ||||||||
| FaxNumber: | 9198343118 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 N JUDD PKWY NE | ||||||||
| Address2: | |||||||||
| City: | FUQUAY VARINA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275262367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195571110 | ||||||||
| FaxNumber: | 9195571102 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2005 | ||||||||
| LastUpdateDate: | 03/22/2022 | ||||||||
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| AuthorizedOfficialLastName: | MCCRAY | ||||||||
| AuthorizedOfficialFirstName: | SCOT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8564494068 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/22/2022 | ||||||||
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 | 344589A | 05 | NC | MEDICAID |