Healthcare Provider Details

I. General information

NPI: 1659146884
Provider Name (Legal Business Name): MY COMMUNITY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2023
Last Update Date: 12/22/2023
Certification Date: 12/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1318 GONDER AVE SE UNIT 1
CANTON OH
44707-3450
US

IV. Provider business mailing address

2600 7TH ST. SW
CANTON OH
44710
US

V. Phone/Fax

Practice location:
  • Phone: 330-639-1071
  • Fax: 330-639-1072
Mailing address:
  • Phone: 330-363-2218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: JUAN PAULO AFABLE
Title or Position: CEO
Credential:
Phone: 330-363-3786