Provider Demographics
NPI:1467034033
Name:COMMUNITY CLINIC, INC.
Entity Type:Organization
Organization Name:COMMUNITY CLINIC, INC.
Other - Org Name:CCI HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SONYA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRUTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-839-5107
Mailing Address - Street 1:8665 GEORGIA AVE
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-3405
Mailing Address - Country:US
Mailing Address - Phone:301-340-7525
Mailing Address - Fax:301-495-0318
Practice Address - Street 1:2730 UNIVERSITY BLVD WEST, #LL10
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:MD
Practice Address - Zip Code:20902
Practice Address - Country:US
Practice Address - Phone:301-933-6680
Practice Address - Fax:301-495-0318
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY CLINIC INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-04-23
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD053601OtherMEDICARE
MD130061000Medicaid