Provider Demographics
NPI:1619342706
Name:ROANOKE CHOWAN COMMUNITY HEALTH CENTER INC
Entity Type:Organization
Organization Name:ROANOKE CHOWAN COMMUNITY HEALTH CENTER INC
Other - Org Name:CRESWELL PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INTERIM, CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:WROTEN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:252-209-0237
Mailing Address - Street 1:PO BOX 669
Mailing Address - Street 2:
Mailing Address - City:AHOSKIE
Mailing Address - State:NC
Mailing Address - Zip Code:27910-0669
Mailing Address - Country:US
Mailing Address - Phone:252-209-0237
Mailing Address - Fax:252-209-0197
Practice Address - Street 1:9500 NC HIGHWAY 94 N
Practice Address - Street 2:
Practice Address - City:CRESWELL
Practice Address - State:NC
Practice Address - Zip Code:27928-8300
Practice Address - Country:US
Practice Address - Phone:252-209-0237
Practice Address - Fax:252-209-0197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-01
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC02CEKOtherBCBS OF NORTH CAROLINA
NC1619342706Medicaid