Provider Demographics
NPI:1073611364
Name:COMMUNITY HEALTH CENTERS, INC.
Entity Type:Organization
Organization Name:COMMUNITY HEALTH CENTERS, INC.
Other - Org Name:72ND STREET MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-412-6920
Mailing Address - Street 1:1455 W 2200 S STE 300
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-7219
Mailing Address - Country:US
Mailing Address - Phone:801-412-6920
Mailing Address - Fax:877-497-4661
Practice Address - Street 1:220 W 7200 S
Practice Address - Street 2:SUITE A
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-1043
Practice Address - Country:US
Practice Address - Phone:801-566-5494
Practice Address - Fax:877-497-4661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1073611364Medicaid
UT000055144Medicare PIN
UT461808Medicare Oscar/Certification