Healthcare Provider Details

I. General information

NPI: 1114137403
Provider Name (Legal Business Name): COMMUNITY HEALTH CENTER OF RICHMOND, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 09/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 PORT RICHMOND AVENUE
STATEN ISLAND NY
10302-1701
US

IV. Provider business mailing address

235 PORT RICHMOND AVENUE
STATEN ISLAND NY
10302-1701
US

V. Phone/Fax

Practice location:
  • Phone: 718-876-1732
  • Fax: 718-442-0189
Mailing address:
  • Phone: 718-924-2254
  • Fax: 718-442-0189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number7004210R
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number2903588
License Number StateNY

VIII. Authorized Official

Name: LUCIE GABRIEL
Title or Position: DIRECTOR OF PATIENT FINANCIAL SERVI
Credential:
Phone: 718-924-2254