Basic Information
| Provider Information | |||||||||
| NPI: | 1104006253 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VALLEY PROFESSIONALS COMMUNITY HEALTH CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 344 | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478420344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7658281003 | ||||||||
| FaxNumber: | 7658281030 | ||||||||
| Practice Location | |||||||||
| Address1: | 777 S MAIN ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CLINTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478422493 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7658281003 | ||||||||
| FaxNumber: | 7658281030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2007 | ||||||||
| LastUpdateDate: | 02/19/2015 | ||||||||
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| AuthorizedOfficialLastName: | WARREN | ||||||||
| AuthorizedOfficialFirstName: | TERRY | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8128281003 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 200884580A | 05 | IN | MEDICAID |