Healthcare Provider Details

I. General information

NPI: 1588480305
Provider Name (Legal Business Name): COMMUNITY CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2024
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 GIRARD ST STE 206
GAITHERSBURG MD
20877-3490
US

IV. Provider business mailing address

8665 GEORGIA AVE
SILVER SPRING MD
20910-3405
US

V. Phone/Fax

Practice location:
  • Phone: 240-720-0510
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: ALISA BRIGHTLEY
Title or Position: LEAD CREDENTIALING SPECIALIST
Credential:
Phone: 240-297-6758