Healthcare Provider Details

I. General information

NPI: 1396780086
Provider Name (Legal Business Name): TRI-COUNTY COMMUNITY ACTION AGENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 12/12/2023
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1126 HARTFORD AVE
JOHNSTON RI
02919-7130
US

IV. Provider business mailing address

1126 HARTFORD AVE
JOHNSTON RI
02919-7130
US

V. Phone/Fax

Practice location:
  • Phone: 401-351-2750
  • Fax: 401-351-6613
Mailing address:
  • Phone: 401-351-2750
  • Fax: 401-351-6613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License NumberACF01507
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: JOSEPH R DESANTIS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 401-519-1967