Basic Information
| Provider Information | |||||||||
| NPI: | 1700027919 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCE COMMUNITY HEALTH, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 ROCK QUARRY RD | ||||||||
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| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276103825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193625201 | ||||||||
| FaxNumber: | 9193875905 | ||||||||
| Practice Location | |||||||||
| Address1: | 212 S SALEM ST | ||||||||
| Address2: | |||||||||
| City: | APEX | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275021825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198333111 | ||||||||
| FaxNumber: | 9198343118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2009 | ||||||||
| LastUpdateDate: | 04/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | WASHINGTON | ||||||||
| AuthorizedOfficialFirstName: | PENELLA | ||||||||
| AuthorizedOfficialMiddleName: | MOTEN | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9192502923 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 04/21/2020 | ||||||||
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 | 344585C | 05 | NC | MEDICAID |