Provider Demographics
NPI:1720462294
Name:PENINSULA INSTITUTE FOR COMMUNITY HEALTH INC
Entity Type:Organization
Organization Name:PENINSULA INSTITUTE FOR COMMUNITY HEALTH INC
Other - Org Name:SOUTHEASTERN VIRGINIA HEALTH SYSTEM AT WESTERN TIDEWATER COMMUNITY SER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:FUTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-591-0643
Mailing Address - Street 1:1033 28TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23607-4233
Mailing Address - Country:US
Mailing Address - Phone:757-591-0643
Mailing Address - Fax:757-228-1045
Practice Address - Street 1:5268 GODWIN BLVD
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8114
Practice Address - Country:US
Practice Address - Phone:757-255-7133
Practice Address - Fax:757-255-7142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-15
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)