Provider Demographics
NPI:1457512766
Name:NEW HANOVER COMMUNITY HEALTH CENTER INCORPORATED
Entity Type:Organization
Organization Name:NEW HANOVER COMMUNITY HEALTH CENTER INCORPORATED
Other - Org Name:LAKESIDE WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ALTHEA
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-202-8623
Mailing Address - Street 1:925 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-3450
Mailing Address - Country:US
Mailing Address - Phone:910-343-0270
Mailing Address - Fax:910-251-1540
Practice Address - Street 1:1805 S 13TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6469
Practice Address - Country:US
Practice Address - Phone:910-772-5552
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEW HANOVER COMMUNITY HEALTH CENTER INCORPORATED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-19
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
34-1923OtherMEDICARE FACILITY IDENTIFICATION NUMBER