Basic Information
| Provider Information | |||||||||
| NPI: | 1639634819 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KINSTON COMMUNITY HEALTH CENTER, INC. | ||||||||
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| OtherOrganizationName: | KINSTON COMMUNITY BEHAVIORAL HEALTH CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 324 N QUEEN ST | ||||||||
| Address2: | |||||||||
| City: | KINSTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285014932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2525229800 | ||||||||
| FaxNumber: | 2525239790 | ||||||||
| Practice Location | |||||||||
| Address1: | 107 S QUEEN ST | ||||||||
| Address2: | |||||||||
| City: | KINSTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285014933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2525229800 | ||||||||
| FaxNumber: | 2525239790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2019 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
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| AuthorizedOfficialLastName: | WALLACE | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | LISA | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2525229800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.