Basic Information
| Provider Information | |||||||||
| NPI: | 1295863884 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY HEALTH CENTERS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 S WOODLAND ST | ||||||||
| Address2: | |||||||||
| City: | WINTER GARDEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347873546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079058827 | ||||||||
| FaxNumber: | 4079058998 | ||||||||
| Practice Location | |||||||||
| Address1: | 1296 W BROAD ST | ||||||||
| Address2: | |||||||||
| City: | GROVELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347362012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524356696 | ||||||||
| FaxNumber: | 8446309996 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2007 | ||||||||
| LastUpdateDate: | 10/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | DICKINSON | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4079058827 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336M0002X | N | Suppliers | Pharmacy | Mail Order Pharmacy | 3336C0002X | PH7505 | FL | Y | Suppliers | Pharmacy | Clinic Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 1040497 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER | 104813990 | 05 | FL | MEDICAID |