Basic Information
| Provider Information | |||||||||
| NPI: | 1275847766 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLACKSTONE VALLEY COMMUNITY HEALTH CARE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 42 PARK PL | ||||||||
| Address2: | |||||||||
| City: | PAWTUCKET | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028604010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017290080 | ||||||||
| FaxNumber: | 4017290438 | ||||||||
| Practice Location | |||||||||
| Address1: | 9 CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | CENTRAL FALLS | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028632005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017220081 | ||||||||
| FaxNumber: | 4017242109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2010 | ||||||||
| LastUpdateDate: | 11/18/2011 | ||||||||
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| AuthorizedOfficialLastName: | LAVOIE | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4017290080 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | ACF01528 | RI | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | BV01759 | 05 | RI | MEDICAID |