Basic Information
Provider Information | |||||||||
NPI: | 1801295936 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LINCOLN COMMUNITY HEALTH CENTER INCORPORATED | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LIVE WELL PRIMARY CARE CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 52119 | ||||||||
Address2: |   | ||||||||
City: | DURHAM | ||||||||
State: | NC | ||||||||
PostalCode: | 277172119 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9199564000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3901 N ROXBORO ST STE 101 | ||||||||
Address2: |   | ||||||||
City: | DURHAM | ||||||||
State: | NC | ||||||||
PostalCode: | 277042181 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9192961758 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/14/2014 | ||||||||
LastUpdateDate: | 07/28/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FOYE | ||||||||
AuthorizedOfficialFirstName: | CLARETTA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 9199564022 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | LINCOLN COMMUNITY HEALTH CENTER INCORPORATED | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
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) |
No ID Information.