Basic Information
| Provider Information | |||||||||
| NPI: | 1366488280 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | METROPOLITAN COMMUNITY HEALTH SERVICES, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AGAPE COMMUNITY HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1886 | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278891886 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2529400602 | ||||||||
| FaxNumber: | 2529400605 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 W MARTIN LUTHER KING JR DR | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278894906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2529400602 | ||||||||
| FaxNumber: | 2529400605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 04/06/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DOBY | ||||||||
| AuthorizedOfficialFirstName: | LAURENCE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2526447003 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP0904X | N | Ambulatory Health Care Facilities | Clinic/Center | Public Health, Federal | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 344591A | 05 | NC | MEDICAID | 890179G | 01 | NC | NORTH CAROLINA ACCESS | OTHER | 0179G | 01 | NC | BCBS | OTHER |