Basic Information
Provider Information
NPI: 1174803886
EntityType: 2
ReplacementNPI:  
OrganizationName: DIMOCK COMUNITY HEALTH CENTER
LastName:  
FirstName:  
MiddleName:  
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Credential:  
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Mailing Information
Address1: 1800 COLUMBUS AVE
Address2:  
City: ROXBURY
State: MA
PostalCode: 021191042
CountryCode: US
TelephoneNumber: 6174428800
FaxNumber: 6174426762
Practice Location
Address1: 1800 COLUMBUS AVE
Address2:  
City: ROXBURY
State: MA
PostalCode: 021191042
CountryCode: US
TelephoneNumber: 6174428800
FaxNumber: 6174426762
Other Information
ProviderEnumerationDate: 08/25/2011
LastUpdateDate: 08/25/2011
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: LOOMIS
AuthorizedOfficialFirstName: CHRISTINE
AuthorizedOfficialMiddleName: ANN
AuthorizedOfficialTitleorPosition: EARLY INTERVENTION SPECIALIST
AuthorizedOfficialTelephone: 6174428800
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
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AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QC1500X261QC1500XMAY Ambulatory Health Care FacilitiesClinic/CenterCommunity Health

No ID Information.


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