Provider Demographics
NPI:1649344821
Name:HENRY LEE WILLIS COMMUNITY CENTER, INC
Entity type:Organization
Organization Name:HENRY LEE WILLIS COMMUNITY CENTER, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CARLTON
Authorized Official - Middle Name:A
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-799-0702
Mailing Address - Street 1:119 FOREST ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-1529
Mailing Address - Country:US
Mailing Address - Phone:508-799-0702
Mailing Address - Fax:508-754-0245
Practice Address - Street 1:44 FRONT ST
Practice Address - Street 2:SUITE 480
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1733
Practice Address - Country:US
Practice Address - Phone:508-799-2934
Practice Address - Fax:508-770-1732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0690261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center