Basic Information
| Provider Information | |||||||||
| NPI: | 1942527874 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREATER PRINCE WILLIAM AREA COMMUNITY HEATLH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GREATER PRINCE WILLIAM COMMUNITY HEALTH CENTER DENTAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6966 | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | VA | ||||||||
| PostalCode: | 232300966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8042377690 | ||||||||
| FaxNumber: | 8042377697 | ||||||||
| Practice Location | |||||||||
| Address1: | 4379 RIDGEWOOD CENTER DR | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | WOODBRIDGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221928322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036807950 | ||||||||
| FaxNumber: | 7036807953 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2010 | ||||||||
| LastUpdateDate: | 07/22/2010 | ||||||||
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| AuthorizedOfficialLastName: | PRINCIPI | ||||||||
| AuthorizedOfficialFirstName: | FRANK | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7036807950 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.