Basic Information
| Provider Information | |||||||||
| NPI: | 1649210279 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LINCOLN COMMUNITY HEALTH CENTER INCORPORATED | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | JOHN H LUCAS SR WELLNESS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 52119 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277172119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199564000 | ||||||||
| FaxNumber: | 9199564535 | ||||||||
| Practice Location | |||||||||
| Address1: | 3727 FAYETTEVILLE ST | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277074718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199564519 | ||||||||
| FaxNumber: | 9196883288 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 07/28/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FOYE | ||||||||
| AuthorizedOfficialFirstName: | CLARETTA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9199564022 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LINCOLN COMMUNITY HEALTH CENTER INCORPORATED | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 344500A | 05 | NC | MEDICAID | 03055 | 01 | NC | NC BC/BS ID NUMBER | OTHER | 344500C | 05 | NC | MEDICAID |