Basic Information
| Provider Information | |||||||||
| NPI: | 1952592180 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AVIS GOODWIN COMMUNITY HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 311 ROUTE 108 | ||||||||
| Address2: | |||||||||
| City: | SOMERSWORTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038781522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037492346 | ||||||||
| FaxNumber: | 6039530066 | ||||||||
| Practice Location | |||||||||
| Address1: | 311 ROUTE 108 | ||||||||
| Address2: | |||||||||
| City: | SOMERSWORTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038781522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037492346 | ||||||||
| FaxNumber: | 6039530066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2007 | ||||||||
| LastUpdateDate: | 08/03/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 08/28/2007 | ||||||||
| NPIReactivationDate: | 07/30/2008 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ATKINS | ||||||||
| AuthorizedOfficialFirstName: | JANET | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6037492346 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | N | Ambulatory Health Care Facilities | Clinic/Center | Dental | 261QC1500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
| ID | Type | State | Issuer | Description | 138790201 | 05 | ME | MEDICAID | 30011037 | 05 | NH | MEDICAID | 999909035 | 05 | ME | MEDICAID |