Basic Information
| Provider Information | |||||||||
| NPI: | 1780815316 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AVIS GOODWIN COMMUNITY HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 652F CENTRAL AVE # F | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038203414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035165270 | ||||||||
| FaxNumber: | 6039530066 | ||||||||
| Practice Location | |||||||||
| Address1: | 388 SOMERSWORTH RD | ||||||||
| Address2: | |||||||||
| City: | NORTH BERWICK | ||||||||
| State: | ME | ||||||||
| PostalCode: | 039066559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035162570 | ||||||||
| FaxNumber: | 6039530066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2009 | ||||||||
| LastUpdateDate: | 07/30/2009 | ||||||||
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| AuthorizedOfficialLastName: | ATKINS | ||||||||
| AuthorizedOfficialFirstName: | JANET | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6035162570 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1000X | N | Ambulatory Health Care Facilities | Clinic/Center | Student Health | 261QC1500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
| ID | Type | State | Issuer | Description | 999909035 | 05 | ME | MEDICAID |