Basic Information
| Provider Information | |||||||||
| NPI: | 1861817504 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MANET COMMUNITY HEALTH CENTER , INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MANET COMMUNITY HEALTH CENTER, INC AT TAUNTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 W SQUANTUM ST | ||||||||
| Address2: | |||||||||
| City: | NORTH QUINCY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021712122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6173763030 | ||||||||
| FaxNumber: | 6176906903 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 WASHINGTON STREET | ||||||||
| Address2: | SUITE 900 | ||||||||
| City: | TAUNTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176906343 | ||||||||
| FaxNumber: | 6176906903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2014 | ||||||||
| LastUpdateDate: | 03/04/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEVINE | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR DIRECTOR STRATEGIC SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 6176906343 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 4801 | MA | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1302841 | 05 | MA | MEDICAID |