Basic Information
Provider Information | |||||||||
NPI: | 1912980251 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMMUNITY HEALTH CARE INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1720 LAKEPOINTE DR STE 117 | ||||||||
Address2: |   | ||||||||
City: | LEWISVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 750576425 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2143793300 | ||||||||
FaxNumber: | 2148539018 | ||||||||
Practice Location | |||||||||
Address1: | 130 SOUTHAMPTON RD | ||||||||
Address2: |   | ||||||||
City: | WESTFIELD | ||||||||
State: | MA | ||||||||
PostalCode: | 010851370 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4135686600 | ||||||||
FaxNumber: | 4135628360 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/21/2005 | ||||||||
LastUpdateDate: | 04/20/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | D'ANDRIA | ||||||||
AuthorizedOfficialFirstName: | GENCO | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 2143793300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/20/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 163WA0400X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Addiction (Substance Use Disorder) | 164W00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Licensed Practical Nurse |   | 207RA0401X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine | 261QM2800X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic | 261QR0405X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
ID | Type | State | Issuer | Description | 110028022C | 05 | MA |   | MEDICAID | 110028022H | 05 | MA |   | MEDICAID | 1307185 | 05 | MA |   | MEDICAID | 110028022B | 05 | MA |   | MEDICAID | 110028022G | 05 | MA |   | MEDICAID | 110028022A | 05 | MA |   | MEDICAID | 110028022E | 05 | MA |   | MEDICAID | 110028022F | 05 | MA |   | MEDICAID | 110028022D | 05 | MA |   | MEDICAID |