Provider Demographics
NPI:1578858247
Name:WARREN COMMUNITY HEALTH CLINIC INC.
Entity Type:Organization
Organization Name:WARREN COMMUNITY HEALTH CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:JONES
Authorized Official - Last Name:SOMERVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:ETC
Authorized Official - Phone:252-257-1904
Mailing Address - Street 1:546 W RIDGEWAY ST
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:NC
Mailing Address - Zip Code:27589-1716
Mailing Address - Country:US
Mailing Address - Phone:252-257-1904
Mailing Address - Fax:252-257-1142
Practice Address - Street 1:546 W RIDGEWAY ST
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:NC
Practice Address - Zip Code:27589-1716
Practice Address - Country:US
Practice Address - Phone:252-257-1904
Practice Address - Fax:252-257-1142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-10
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCD901OtherPROVIDER TRANSACTION ACCESS NUMBER(PTAN)