Provider Demographics
NPI:1619287638
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 1:200 GIRARD ST
Practice Address - Street 2:SUITE 206
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-3466
Practice Address - Country:US
Practice Address - Phone:240-720-0510
Practice Address - Fax:240-631-2280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-08
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD142171223G0001X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD331504500Medicaid
MD053601OtherMEDICARE PIN