Provider Demographics
NPI:1942930748
Name:COMMUNITY CARE CLINIC OF DARE
Entity Type:Organization
Organization Name:COMMUNITY CARE CLINIC OF DARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LYN
Authorized Official - Middle Name:MATHIS
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:BSN RN
Authorized Official - Phone:252-261-3041
Mailing Address - Street 1:PO BOX 1329
Mailing Address - Street 2:
Mailing Address - City:NAGS HEAD
Mailing Address - State:NC
Mailing Address - Zip Code:27959-1329
Mailing Address - Country:US
Mailing Address - Phone:252-261-3041
Mailing Address - Fax:252-255-6352
Practice Address - Street 1:425 W HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:NAGS HEAD
Practice Address - State:NC
Practice Address - Zip Code:27959-8944
Practice Address - Country:US
Practice Address - Phone:252-261-3041
Practice Address - Fax:252-255-6352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-14
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty