Basic Information
| Provider Information | |||||||||
| NPI: | 1497729750 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEALTHREACH COMMUNITY HEALTH CENTERS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | RANGELEY FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 569 | ||||||||
| Address2: | 42 DALLAS HILL ROAD | ||||||||
| City: | RANGELEY | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078643947 | ||||||||
| FaxNumber: | 2078642969 | ||||||||
| Practice Location | |||||||||
| Address1: | 42 DALLAS HILL RD | ||||||||
| Address2: | |||||||||
| City: | RANGELEY | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078643303 | ||||||||
| FaxNumber: | 2078642969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 07/07/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COGGINS | ||||||||
| AuthorizedOfficialFirstName: | CONSTANCE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 2078613407 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | E58728 | ME | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 137970110 | 05 | ME | MEDICAID |