Basic Information
| Provider Information | |||||||||
| NPI: | 1205566106 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY HEALTH CONNECTIONS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 326 NICHOLS RD | ||||||||
| Address2: | |||||||||
| City: | FITCHBURG | ||||||||
| State: | MA | ||||||||
| PostalCode: | 014201914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9788788100 | ||||||||
| FaxNumber: | 9788788537 | ||||||||
| Practice Location | |||||||||
| Address1: | 165 MILL ST | ||||||||
| Address2: | |||||||||
| City: | LEOMINSTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 014533289 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9788788100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2022 | ||||||||
| LastUpdateDate: | 08/24/2022 | ||||||||
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| AuthorizedOfficialLastName: | DEMALIA | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 9788788510 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY HEALTH CONNECTIONS, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 08/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | N | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 221962 | 05 | MA | MEDICAID | M21400 | 01 | MA | MEDICARE PART B PIN | OTHER | 110028187L | 05 | MA | MEDICAID |