Provider Demographics
NPI:1376708560
Name:THUNDERMIST HEALTH CENTER
Entity Type:Organization
Organization Name:THUNDERMIST HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:CKARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:AGUDELO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-767-4100
Mailing Address - Street 1:171 SERVICE AVE STE 330
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-1015
Mailing Address - Country:US
Mailing Address - Phone:401-767-4100
Mailing Address - Fax:401-235-6833
Practice Address - Street 1:186 PROVIDENCE ST
Practice Address - Street 2:
Practice Address - City:WEST WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02893-2508
Practice Address - Country:US
Practice Address - Phone:401-615-2800
Practice Address - Fax:401-615-2805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-28
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIACF01610251S00000X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI4101805Medicaid
709000181Medicare PIN
RI4101805Medicaid