1467034033 NPI number — COMMUNITY CLINIC, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467034033 NPI number — COMMUNITY CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY CLINIC, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467034033
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8665 GEORGIA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SILVER SPRING
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20910-3405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-340-7525
Provider Business Mailing Address Fax Number:
301-495-0318

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2730 UNIVERSITY BLVD WEST, #LL10
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHEATON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-933-6680
Provider Business Practice Location Address Fax Number:
301-495-0318
Provider Enumeration Date:
04/23/2021

Additional Information

Authorized Official

Authorized Official Last Name:
BRUTON
Authorized Official First Name:
SONYA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
240-839-5107

Provider Taxonomy Codes

  • Taxonomy code: 2251P0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QC1500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 053601 . This is a "MEDICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 130061000 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com