Provider Demographics
NPI:1104046226
Name:BLACKSTONE VALLEY COMMUNITY HEALTH CARE
Entity type:Organization
Organization Name:BLACKSTONE VALLEY COMMUNITY HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:J
Authorized Official - Last Name:LAVOIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-312-9892
Mailing Address - Street 1:39 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-4003
Mailing Address - Country:US
Mailing Address - Phone:401-312-9892
Mailing Address - Fax:401-312-0139
Practice Address - Street 1:210 MAIN ST
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-4008
Practice Address - Country:US
Practice Address - Phone:401-312-9892
Practice Address - Fax:401-312-0139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-30
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIACG01536261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIBVCHC09336Medicaid