Provider Demographics
NPI:1811303068
Name:CENTER STREET COMMUNITY CLINIC, INC
Entity type:Organization
Organization Name:CENTER STREET COMMUNITY CLINIC, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:COBB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-751-4531
Mailing Address - Street 1:136 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-3704
Mailing Address - Country:US
Mailing Address - Phone:740-751-4189
Mailing Address - Fax:740-751-4866
Practice Address - Street 1:76 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT GILEAD
Practice Address - State:OH
Practice Address - Zip Code:43338-1471
Practice Address - Country:US
Practice Address - Phone:419-946-3856
Practice Address - Fax:194-751-7351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-09
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH361965Medicare UPIN