Provider Demographics
NPI:1962681734
Name:BOONE COUNTY COMMUNITY HEALTH CLINIC, INC
Entity Type:Organization
Organization Name:BOONE COUNTY COMMUNITY HEALTH CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BAMBI
Authorized Official - Middle Name:
Authorized Official - Last Name:MCQUADE-JONES
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, FNP-C
Authorized Official - Phone:765-483-4469
Mailing Address - Street 1:416 W CAMP ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-1799
Mailing Address - Country:US
Mailing Address - Phone:765-483-4469
Mailing Address - Fax:
Practice Address - Street 1:416 W CAMP ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-1799
Practice Address - Country:US
Practice Address - Phone:765-483-4469
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000784B261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100063430Medicaid
IN200401120AMedicaid
IN200432840Medicaid
IN100063430Medicaid