Basic Information
Provider Information | |||||||||
NPI: | 1891271938 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMMUNITY ACTION COMMITTEE OF PIKE COUNTY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | VALLEY VIEW HEALTH CENTER-EMMITT AVENUE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 941 MARKET ST | ||||||||
Address2: |   | ||||||||
City: | PIKETON | ||||||||
State: | OH | ||||||||
PostalCode: | 456619757 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7402892371 | ||||||||
FaxNumber: | 7402894291 | ||||||||
Practice Location | |||||||||
Address1: | 715 W EMMITT AVE | ||||||||
Address2: |   | ||||||||
City: | WAVERLY | ||||||||
State: | OH | ||||||||
PostalCode: | 456901015 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7409478777 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2018 | ||||||||
LastUpdateDate: | 06/09/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BELLOMY | ||||||||
AuthorizedOfficialFirstName: | LORI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
AuthorizedOfficialTelephone: | 7409477726 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/09/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   | OH | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 0329341 | 05 | OH |   | MEDICAID |