Provider Demographics
NPI:1710235551
Name:COMMUNITY HEALTH CLINIC, INC.
Entity Type:Organization
Organization Name:COMMUNITY HEALTH CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:RAJI
Authorized Official - Middle Name:
Authorized Official - Last Name:DANDAPANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-335-3334
Mailing Address - Street 1:943 FOURTH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW KENSINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15068-6409
Mailing Address - Country:US
Mailing Address - Phone:724-335-3334
Mailing Address - Fax:724-335-2283
Practice Address - Street 1:947 FOURTH AVENUE
Practice Address - Street 2:
Practice Address - City:NEW KENSINGTON
Practice Address - State:PA
Practice Address - Zip Code:15068
Practice Address - Country:US
Practice Address - Phone:724-335-2862
Practice Address - Fax:724-335-2283
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY HEALTH CLINIC, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-28
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS019493L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1012676430004Medicaid