Healthcare Provider Details

I. General information

NPI: 1619319043
Provider Name (Legal Business Name): RICHARD D WATKINS CANTON COMMUNITY CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2013
Last Update Date: 07/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 MAHONING RD NE
CANTON OH
44705-3335
US

IV. Provider business mailing address

2725 LINCOLN ST E
CANTON OH
44707-2769
US

V. Phone/Fax

Practice location:
  • Phone: 330-454-2000
  • Fax: 330-454-6184
Mailing address:
  • Phone: 330-454-2000
  • Fax: 330-454-7284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: DAVID COLA
Title or Position: CEO
Credential: DO
Phone: 330-454-2000