Basic Information
| Provider Information | |||||||||
| NPI: | 1407229651 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHARLES B. WANG COMMUNITY HEALTH CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 268 CANAL ST | ||||||||
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| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100133599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123796988 | ||||||||
| FaxNumber: | 2123796936 | ||||||||
| Practice Location | |||||||||
| Address1: | 13739 45TH AVE | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113554094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9293623018 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2015 | ||||||||
| LastUpdateDate: | 11/10/2015 | ||||||||
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| AuthorizedOfficialLastName: | ENG | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2123796988 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 7002107R | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 00356318 | 05 | NY | MEDICAID |