Healthcare Provider Details

I. General information

NPI: 1477545549
Provider Name (Legal Business Name): THE PROVIDENCE COMMUNITY HEALTH CENTERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355R PRAIRIE AVE SUITE 3
PROVIDENCE RI
02905-1961
US

IV. Provider business mailing address

375 ALLENS AVE
PROVIDENCE RI
02905-5010
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-0430
  • Fax: 401-444-0489
Mailing address:
  • Phone: 401-444-0400
  • Fax: 401-444-0468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: KEVIN CABRAL
Title or Position: CFO
Credential:
Phone: 401-444-0400