Healthcare Provider Details

I. General information

NPI: 1720289903
Provider Name (Legal Business Name): RICHARD D WATKINS CANTON COMMUNITY CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 05/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2725 LINCOLN ST E
CANTON OH
44707-2769
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: 330-454-6184

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: PENNY A GEMBAROSKY
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 330-454-2000