Basic Information
| Provider Information | |||||||||
| NPI: | 1922617695 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH CENTERS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FOUR CORNERS - COMMUNITY HEALTH CENTERS, INC. | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 S WOODLAND ST | ||||||||
| Address2: | |||||||||
| City: | WINTER GARDEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347873546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079058227 | ||||||||
| FaxNumber: | 4079058827 | ||||||||
| Practice Location | |||||||||
| Address1: | 509 CAGAN VIEW RD | ||||||||
| Address2: | |||||||||
| City: | CLERMONT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347146405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079058827 | ||||||||
| FaxNumber: | 4079058827 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2020 | ||||||||
| LastUpdateDate: | 04/21/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DICKINSON | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4079058827 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY HEALTH CENTERS, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 261QP2300X | 01 | TAXONOMY | OTHER |