Provider Demographics
NPI:1467714618
Name:COMMUNITY CARE CENTER CORPORATION
Entity Type:Organization
Organization Name:COMMUNITY CARE CENTER CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-870-5483
Mailing Address - Street 1:1216 E BALTIMORE ST
Mailing Address - Street 2:ATTN: COMMUNITY CARE CENTER
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21202-4710
Mailing Address - Country:US
Mailing Address - Phone:410-870-5483
Mailing Address - Fax:
Practice Address - Street 1:1216 E BALTIMORE ST
Practice Address - Street 2:ATTN: COMMUNITY CARE CENTER
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21202-4710
Practice Address - Country:US
Practice Address - Phone:410-870-5483
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-13
Last Update Date:2012-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care