Basic Information
| Provider Information | |||||||||
| NPI: | 1912328600 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRI-COUNTY COMMUNITY ACTION AGENCY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | TRI-COUNTY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1126 HARTFORD AVE | ||||||||
| Address2: | |||||||||
| City: | JOHNSTON | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029197109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4013512750 | ||||||||
| FaxNumber: | 4013516611 | ||||||||
| Practice Location | |||||||||
| Address1: | 33 MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | NORTH PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029112415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4013512750 | ||||||||
| FaxNumber: | 4013516611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2013 | ||||||||
| LastUpdateDate: | 06/29/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DESANTIS | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4015191967 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 06/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | RI | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.