Basic Information
| Provider Information | |||||||||
| NPI: | 1821120924 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE PROVIDENCE COMMUNITY HEALTH CENTERS, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CROSSROADS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 375 ALLENS AVE | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029055010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4014440400 | ||||||||
| FaxNumber: | 4014440468 | ||||||||
| Practice Location | |||||||||
| Address1: | 160 BROAD ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4018612403 | ||||||||
| FaxNumber: | 4015211145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 03/29/2017 | ||||||||
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| AuthorizedOfficialLastName: | YOUNG | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT/CHIEF FINANCIAL OFFI | ||||||||
| AuthorizedOfficialTelephone: | 4014440400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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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.