Basic Information
| Provider Information | |||||||||
| NPI: | 1386883296 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | POLK COUNTY COMMUNITY HEALTH & WELLNESS CENTER, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 130 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287220130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8288942222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 801 W MILLS ST STE A&B | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287228494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8288942222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2009 | ||||||||
| LastUpdateDate: | 03/04/2009 | ||||||||
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| AuthorizedOfficialLastName: | STARK | ||||||||
| AuthorizedOfficialFirstName: | MARY JO | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8288942222 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 6102994 | 05 | NC | MEDICAID | 7912153 | 05 | NC | MEDICAID | 6005017 | 05 | NC | MEDICAID | 1740484575 | 01 | NC | NPI | OTHER | 6106296 | 05 | NC | MEDICAID | 6000122 | 05 | NC | MEDICAID |