MEDICARE: TRI COUNTY COMMUNITY HEALTH COUNCIL INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM1300X	Multi-Specialty Clinic/Center

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2804165	OTHER	NC	MEDICARE PIN

General Provider Information

NPI Number	:	1134422041
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRI COUNTY COMMUNITY HEALTH COUNCIL INC

Provider Business Mailing Address
First Line	:	PO BOX 340
Second Line	:
City	:	FOUR OAKS
State	:	NC
Zip	:	27524-0340
Country	:	US
Telephone Number	:	910-567-6194
Fax Number	:	910-567-4389

Provider Business Practice Location Address
First Line	:	417 VANCE ST UNIT B
Second Line	:
City	:	CLINTON
State	:	NC
Zip	:	28328-4001
Country	:	US
Telephone Number	:	910-567-7107
Fax Number	:	910-299-0486

Authorized Official
Title or Position	:	REVENUE CYCLE MANAGER
Name	:	WILLIAM C ELLISON
Credential	:
Telephone Number	:	910-567-7065

Provider Enumeration Date	:	12/15/2010
Last Update Date	:	04/20/2022

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