Basic Information
| Provider Information | |||||||||
| NPI: | 1740787340 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MANET COMMUNITY HEALTH CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 W SQUANTUM ST STE 8 | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021712158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176906343 | ||||||||
| FaxNumber: | 6177741905 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 W SQUANTUM ST STE 8 | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021712158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176906343 | ||||||||
| FaxNumber: | 6177741905 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2018 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| AuthorizedOfficialLastName: | COVELLUZZI | ||||||||
| AuthorizedOfficialFirstName: | GAIL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6176906353 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 261QF0400X | 4801 | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 110027788C | 05 | MA | MEDICAID |