Basic Information
| Provider Information | |||||||||
| NPI: | 1780064832 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | APPALACHIAN MOUNTAIN COMMUNITY HEALTH CENTERS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | TALLULAH COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2597 | ||||||||
| Address2: | |||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288022597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282025200 | ||||||||
| FaxNumber: | 8284124377 | ||||||||
| Practice Location | |||||||||
| Address1: | 409 TALLULAH RD | ||||||||
| Address2: | |||||||||
| City: | ROBBINSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287718500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284796434 | ||||||||
| FaxNumber: | 8284792674 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2015 | ||||||||
| LastUpdateDate: | 04/06/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PETTIFORD | ||||||||
| AuthorizedOfficialFirstName: | REUBEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8282025335 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MPA | ||||||||
| NPICertificationDate: | |||||||||
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 | 1780064832 | 05 | NC | MEDICAID |