Basic Information
| Provider Information | |||||||||
| NPI: | 1366033532 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE PROVIDENCE COMMUNITY HEALTH CENTERS INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 375 ALLENS AVE | ||||||||
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| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029055010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017802511 | ||||||||
| FaxNumber: | 4017802565 | ||||||||
| Practice Location | |||||||||
| Address1: | 434 MOUNT PLEASANT AVE | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029083302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8886127242 | ||||||||
| FaxNumber: | 4014440421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2021 | ||||||||
| LastUpdateDate: | 02/01/2021 | ||||||||
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| AuthorizedOfficialLastName: | CHARPENTIER | ||||||||
| AuthorizedOfficialFirstName: | BRENDA | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 4017802511 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.