Basic Information
| Provider Information | |||||||||
| NPI: | 1467483297 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MANET COMMUNITY HEALTH CENTER, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MANET COMMUNITY HEALTH CENTER, INC. AT NORTH QUINCY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 W SQUANTUM ST | ||||||||
| Address2: | |||||||||
| City: | NORTH QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021712122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173763030 | ||||||||
| FaxNumber: | 6177741906 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 W SQUANTUM ST | ||||||||
| Address2: | |||||||||
| City: | NORTH QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021712122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173763000 | ||||||||
| FaxNumber: | 6177741905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCGUIRE | ||||||||
| AuthorizedOfficialFirstName: | ANTONIA | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6173763030 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | R.N., M.P.H. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 4801 | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1300571 | 05 | MA | MEDICAID |