Basic Information
| Provider Information | |||||||||
| NPI: | 1285171199 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THREE LOWER COUNTIES COMMUNITY SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1978 | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218021978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107491015 | ||||||||
| FaxNumber: | 4107491020 | ||||||||
| Practice Location | |||||||||
| Address1: | 9956 N MAIN ST | ||||||||
| Address2: | UNIT# 2 | ||||||||
| City: | BERLIN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218111077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109732820 | ||||||||
| FaxNumber: | 4109732843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2017 | ||||||||
| LastUpdateDate: | 09/28/2018 | ||||||||
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| AuthorizedOfficialLastName: | HOLLAND | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 4107491015 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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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 | 119591300 | 05 | MD | MEDICAID |