Basic Information
| Provider Information | |||||||||
| NPI: | 1609946821 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTH COUNTRY FAMILY HEALTH CENTER, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | NORTH COUNTRY CHILDREN'S CLINIC, INC. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 238 ARSENAL STREET | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157829450 | ||||||||
| FaxNumber: | 3157822643 | ||||||||
| Practice Location | |||||||||
| Address1: | 238 ARSENAL STREET | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157829450 | ||||||||
| FaxNumber: | 3157822643 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 05/07/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HORTON | ||||||||
| AuthorizedOfficialFirstName: | JOEY | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3157829450 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MBA | ||||||||
| NPICertificationDate: | 05/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251V00000X | 2201202R | NY | N | Agencies | Voluntary or Charitable | 251V00000X | NY | N | Agencies | Voluntary or Charitable | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 00583702 | 05 | NY | MEDICAID |