Provider Demographics
NPI:1639445034
Name:CHARLES RIVER COMMUNITY HEALTH CENTER
Entity Type:Organization
Organization Name:CHARLES RIVER COMMUNITY HEALTH CENTER
Other - Org Name:CHARLES RIVER COMMUNITY HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR,AO
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-208-1511
Mailing Address - Street 1:43 FOUNDRY AVE
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-8313
Mailing Address - Country:US
Mailing Address - Phone:781-693-3873
Mailing Address - Fax:781-693-3810
Practice Address - Street 1:43 FOUNDRY AVE
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-8313
Practice Address - Country:US
Practice Address - Phone:781-693-3873
Practice Address - Fax:781-693-3810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-29
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0002X
MADS900573336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2134273OtherPK
MA10024306SMedicaid
2134273OtherPK