Provider Demographics
NPI:1720289903
Name:RICHARD D WATKINS CANTON COMMUNITY CLINIC, INC.
Entity Type:Organization
Organization Name:RICHARD D WATKINS CANTON COMMUNITY CLINIC, INC.
Other - Org Name:CANTON COMMUNITY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:A
Authorized Official - Last Name:GEMBAROSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-454-2000
Mailing Address - Street 1:2725 LINCOLN ST E
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44707-2769
Mailing Address - Country:US
Mailing Address - Phone:330-454-2000
Mailing Address - Fax:330-454-6184
Practice Address - Street 1:2725 LINCOLN ST E
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44707-2769
Practice Address - Country:US
Practice Address - Phone:330-454-2000
Practice Address - Fax:330-454-6184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)