Basic Information
Provider Information | |||||||||
NPI: | 1891953048 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMMUNITY HEALTH CONNECTIONS, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LEOMINSTER COMMUNITY HEALTH CONNECTIONS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 326 NICHOLS ROAD | ||||||||
Address2: |   | ||||||||
City: | FITCHBURG | ||||||||
State: | MA | ||||||||
PostalCode: | 014201914 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9788788100 | ||||||||
FaxNumber: | 9788788418 | ||||||||
Practice Location | |||||||||
Address1: | 14 MANNING AVENUE | ||||||||
Address2: |   | ||||||||
City: | LEOMINSTER | ||||||||
State: | MA | ||||||||
PostalCode: | 014535768 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9788470110 | ||||||||
FaxNumber: | 9788470112 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2008 | ||||||||
LastUpdateDate: | 08/24/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DEMALIA | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
AuthorizedOfficialTelephone: | 9788788510 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | COMMUNITY HEALTH CONNECTIONS, INC. | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/24/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   | MA | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 1304780 | 05 | MA |   | MEDICAID | M21400 | 01 | MA | MEDICARE | OTHER | 221893 | 01 | WI | MEDICARE UGS | OTHER |