Provider Demographics
NPI:1417284043
Name:VALLEY PROFESSIONALS COMMUNITY HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:VALLEY PROFESSIONALS COMMUNITY HEALTH CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-492-9042
Mailing Address - Street 1:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IN
Mailing Address - Zip Code:47842-0344
Mailing Address - Country:US
Mailing Address - Phone:765-492-9042
Mailing Address - Fax:765-492-9048
Practice Address - Street 1:703 W PARK ST
Practice Address - Street 2:
Practice Address - City:CAYUGA
Practice Address - State:IN
Practice Address - Zip Code:47928-8207
Practice Address - Country:US
Practice Address - Phone:765-492-9042
Practice Address - Fax:765-492-9048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-03
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200884580BMedicaid
IN200884580BMedicaid
IN151860Medicare Oscar/Certification