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	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1225584287
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	:	910-567-5342

Provider Business Practice Location Address
First Line	:	1508 MAPLE GROVE CHURCH RD
Second Line	:	UNIT 1
City	:	DUNN
State	:	NC
Zip	:	28334-7688
Country	:	US
Telephone Number	:	877-935-5255
Fax Number	:	910-236-2118

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

Provider Enumeration Date	:	08/30/2016
Last Update Date	:	03/27/2024

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