=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780286625
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY HEALTH CENTER OF PINELLAS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2020
-----------------------------------------------------
Last Update Date | 10/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 721 EAST LIME STREET
-----------------------------------------------------
City | TARPON SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34689
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-824-8181
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14100 58TH ST N
-----------------------------------------------------
City | CLEARWATER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33760-9900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-824-8181
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF REGULATORY OFFICER
-----------------------------------------------------
Name | EDWARD KUCHER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 727-824-8100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------