Provider Demographics
NPI:1942840871
Name:CENTER STREET COMMUNITY CLINIC INC
Entity Type:Organization
Organization Name:CENTER STREET COMMUNITY CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:COBB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-751-4531
Mailing Address - Street 1:136 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-3704
Mailing Address - Country:US
Mailing Address - Phone:740-751-4531
Mailing Address - Fax:740-751-4866
Practice Address - Street 1:126 HARDING WAY E
Practice Address - Street 2:
Practice Address - City:GALION
Practice Address - State:OH
Practice Address - Zip Code:44833-1901
Practice Address - Country:US
Practice Address - Phone:740-751-6380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTER STREET COMMUNITY CLINIC INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)