=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679038293
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARING COMMUNITY HEALTH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2019
-----------------------------------------------------
Last Update Date | 01/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 175 S WILKES BARRE BLVD
-----------------------------------------------------
City | WILKES BARRE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18702-5040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-829-2621
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 660 BALTIMORE DR STE 125
-----------------------------------------------------
City | WILKES BARRE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18702-7962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MATT ROGERS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 570-271-6781
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0505X
-----------------------------------------------------
Taxonomy Name | Adult Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------