NPIMap

Organization Active NPI

Tri-County Community Action Agency

  • Federally Qualified Health Center (FQHC)
  • Johnston, RI
National Provider Identifier
1396780086
Registry record updated Dec 12, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
ACF01507 Issued in RI
Legal business name
TRI-COUNTY COMMUNITY ACTION AGENCY
Practice address
1126 Hartford Ave
Johnston, RI 02919-7130
Phone
(401) 351-2750
Fax
(401) 351-6613
NPI assigned
Jun 18, 2006
Last updated
Dec 12, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 12, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Joseph R Desantis
Title
Chief Executive Officer
Phone
(401) 519-1967

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Dental Clinic/Center 261QD0000X NU
Federally Qualified Health Center (FQHC) 261QF0400X ACF01507 RI Primary
Oral and Maxillofacial Surgery Clinic/Center 261QS0112X NU
Community/Behavioral Health Agency 251S00000X NU

Addresses

Primary practice location

1126 Hartford Ave
Johnston, RI 02919-7130

Mailing address

1126 Hartford Ave
Johnston, RI 02919-7130
Phone (401) 351-2750

Other identifiers 1

IdentifierTypeStateIssuer
TT02485MedicaidRI

Other names 1

  • Tri-Town Economic Opportunity Committee Former legal business name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in RI2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040116000778 RI Part B Supplier - Clinic/Group Practice 0648171181 Receives reassigned benefits from 29 practitioners
Practice locations: North Providence, RI; Johnston, RI
O20120201000964 RI Part A Provider - Federally Qualified Health Center (FQHC) 0648171181 Practice locations: Johnston, RI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1396780086. Details of each certification follow.

Federally qualified health center certification: CCN 411812

Legal name
TRI-COUNTY COMMUNITY ACTION AGENCY
Doing business as
TRI-TOWN HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 6, 1997
Last certification
Mar 6, 1997
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Aug 17, 1965 in RI
Enrollment address
1126 Hartford Ave
Johnston, RI 29197109

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Tri-County Community Action16 organizations share this tax ID, including this one

Other organizations with this tax ID 15

Organizations that report the same tax identification number in the National Provider Directory.

View all 15

Locations

1637 Mineral Spring Ave
Ste 101
North Providence, RI 02904
Phone (401) 519-1940

Ownership & related parties

All disclosed owners & managing parties 13

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Jocelyn Tavarez Individual Corporate DirectorBoard Member Nov 1, 2022
Saikon Gbehan Individual Corporate DirectorBoard of Directors Dec 1, 2013
Richard Delfino Individual Corporate DirectorBoard Member Oct 1, 1997
Amber Champlin Individual Corporate DirectorBoard Member Nov 1, 2022
John a Stoukides Individual Corporate DirectorBoard Member Nov 1, 2022
Joseph R Desantis Individual Corporate OfficerPresident/Ceo Mar 10, 1980
W-2 Managing EmployeePresident/Ceo Mar 10, 1980
Robert O'Brien Individual Corporate DirectorChair-Board of Directors Jan 1, 1994
Cheryl Jackson Individual Corporate DirectorSecretary-Board of Directors Mar 1, 1995
Ben Zanni Individual Corporate DirectorBoard of Directors May 1, 2001
Paul Macdonald Individual Corporate DirectorBoard Member Sep 1, 2010
Lynne Finnegan Individual Corporate DirectorVice Chair-Board of Directors Nov 1, 2022
Paul Gott Individual Corporate Director Nov 1, 2010
Edward Gemma Individual Corporate DirectorTreasurer-Board of Directors Nov 1, 2022

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Tri-County Community Health Center of North ProvidenceNorth Providence, RI, CCN 411847 Federally qualified health center 5% Or Greater Security Interest (100%) Jun 1, 2013

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 31

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 31

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1150588800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1702339200000",
    "number": "1396780086",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1126 HARTFORD AVE",
            "city": "JOHNSTON",
            "state": "RI",
            "postal_code": "029197130",
            "telephone_number": "401-351-2750",
            "fax_number": "401-351-6613"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1126 HARTFORD AVE",
            "city": "JOHNSTON",
            "state": "RI",
            "postal_code": "029197130",
            "telephone_number": "401-351-2750",
            "fax_number": "401-351-6613"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TRI-COUNTY COMMUNITY ACTION AGENCY",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-18",
        "last_updated": "2023-12-12",
        "certification_date": "2023-12-12",
        "status": "A",
        "authorized_official_last_name": "DESANTIS",
        "authorized_official_first_name": "JOSEPH",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "401-519-1967"
    },
    "taxonomies": [
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "RI",
            "license": "ACF01507",
            "primary": true
        },
        {
            "code": "261QS0112X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Oral and Maxillofacial Surgery",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "TT02485",
            "state": "RI"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Tri-Town Economic Opportunity Committee",
            "code": "4",
            "type": "Former Legal Business Name"
        },
        {
            "organization_name": "Tri-Town Economic Opportunity Committee",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Johnston, RI

Sources for this page

Verify at the official NPI Registry.