Healthcare Provider Details

I. General information

NPI: 1649414517
Provider Name (Legal Business Name): TRI COUNTY COMMUNITY HEALTH COUNCIL INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2009
Last Update Date: 03/27/2024
Certification Date: 03/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1508 MAPLE GROVE CHURCH RD STE B
DUNN NC
28334-7688
US

IV. Provider business mailing address

PO BOX 340
FOUR OAKS NC
27524-0340
US

V. Phone/Fax

Practice location:
  • Phone: 877-935-5255
  • Fax: 910-236-2118
Mailing address:
  • Phone: 910-567-6194
  • Fax: 910-567-5552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberMHL082078
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM C ELLISON
Title or Position: REVENUE CYCLE MANAGER
Credential:
Phone: 910-567-7065