Provider Demographics
NPI:1245219070
Name:NORTHWEST COMMUNITY HEALTH CARE
Entity Type:Organization
Organization Name:NORTHWEST COMMUNITY HEALTH CARE
Other - Org Name:WELLONE PRIMARY MEDICAL AND DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOPPER
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:401-568-7664
Mailing Address - Street 1:PO BOX 312
Mailing Address - Street 2:
Mailing Address - City:PASCOAG
Mailing Address - State:RI
Mailing Address - Zip Code:02859
Mailing Address - Country:US
Mailing Address - Phone:401-567-0800
Mailing Address - Fax:401-567-0900
Practice Address - Street 1:36 BRIDGE WAY
Practice Address - Street 2:
Practice Address - City:PASCOAG
Practice Address - State:RI
Practice Address - Zip Code:02859
Practice Address - Country:US
Practice Address - Phone:401-567-0800
Practice Address - Fax:401-567-0900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-11
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIACF01571261Q00000X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
RINC50602Medicaid
RI411814Medicare PIN
RI709004025Medicare Oscar/Certification