Provider Demographics
NPI:1336563188
Name:DIMOCK COMMUNITY HEALTH CENTER
Entity Type:Organization
Organization Name:DIMOCK COMMUNITY HEALTH CENTER
Other - Org Name:THE DIMOCK CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KERLLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:AIME'
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-442-8800
Mailing Address - Street 1:55 DIMOCK ST
Mailing Address - Street 2:CREDENTIALING OFFICE
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-1029
Mailing Address - Country:US
Mailing Address - Phone:617-442-8800
Mailing Address - Fax:617-427-2784
Practice Address - Street 1:55 DIMOCK ST
Practice Address - Street 2:CREDENTIALING OFFICE
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02119-1029
Practice Address - Country:US
Practice Address - Phone:617-442-8800
Practice Address - Fax:617-427-2784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-14
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM21066OtherMEDICARE PTAN