Provider Demographics
NPI:1588691620
Name:THUNDERMIST HEALTH CENTER
Entity type:Organization
Organization Name:THUNDERMIST HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:CKARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:AGUDELO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-767-4100
Mailing Address - Street 1:171 SERVICE AVE STE 330
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-1015
Mailing Address - Country:US
Mailing Address - Phone:401-767-4100
Mailing Address - Fax:401-235-6833
Practice Address - Street 1:450 CLINTON ST
Practice Address - Street 2:
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-3207
Practice Address - Country:US
Practice Address - Phone:401-767-4100
Practice Address - Fax:401-235-6882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X, 251B00000X
RIACF01584251S00000X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1588691620Medicaid
RIACF01584OtherOACF
RITH02580Medicaid
RI4101805Medicaid
RI4101805Medicaid