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NPI Code Detail

MEDICARE: RICHARD D WATKINS CANTON COMMUNITY CLINIC, INC.

MEDICARE: RICHARD D WATKINS CANTON COMMUNITY CLINIC, INC.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QF0400XFederally Qualified Health Center (FQHC)

General Provider Information

NPI Number : 1720289903
Entity Type Code : Organization
Provider Name (Legal Business Name) : RICHARD D WATKINS CANTON COMMUNITY CLINIC, INC.
Provider Business Mailing Address
First Line : 2725 LINCOLN ST E
Second Line :
City : CANTON
State : OH
Zip : 44707-2769
Country : US
Telephone Number : 330-454-2000
Fax Number : 330-454-6184
Provider Business Practice Location Address
First Line : 2725 LINCOLN ST E
Second Line :
City : CANTON
State : OH
Zip : 44707-2769
Country : US
Telephone Number : 330-454-2000
Fax Number : 330-454-6184
Authorized Official
Title or Position : CHIEF FINANCIAL OFFICER
Name : PENNY A GEMBAROSKY
Credential :
Telephone Number : 330-454-2000
Provider Enumeration Date : 05/29/2007
Last Update Date : 05/08/2008

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