Basic Information
Provider Information | |||||||||
NPI: | 1457406282 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DIMOCK COMMUNITY HEALTH CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DIMOCK CHC OPTICAL SHOP | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 55 DIMOCK ST | ||||||||
Address2: |   | ||||||||
City: | ROXBURY | ||||||||
State: | MA | ||||||||
PostalCode: | 021191029 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6174428800 | ||||||||
FaxNumber: | 6174450099 | ||||||||
Practice Location | |||||||||
Address1: | 55 DIMOCK ST | ||||||||
Address2: |   | ||||||||
City: | ROXBURY | ||||||||
State: | MA | ||||||||
PostalCode: | 021191029 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6174428800 | ||||||||
FaxNumber: | 6174450099 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/24/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WHITHAM | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF IT & AR | ||||||||
AuthorizedOfficialTelephone: | 6174428800 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X |   | MA | Y |   | Suppliers | Eyewear Supplier (Equipment, not the service) |   |
ID Information
ID | Type | State | Issuer | Description | 1301144 | 05 | MA |   | MEDICAID |