Basic Information
| Provider Information | |||||||||
| NPI: | 1164747929 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REGENESIS ORGANIZATION COMMUNITY HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5158 | ||||||||
| Address2: | |||||||||
| City: | SPARTANBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293045158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645822411 | ||||||||
| FaxNumber: | 8645827178 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 S CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | SPARTANBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293065348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8646993283 | ||||||||
| FaxNumber: | 8646993284 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2010 | ||||||||
| LastUpdateDate: | 01/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | HUNTER | ||||||||
| AuthorizedOfficialFirstName: | MARLON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8645822817 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | REGENESIS ORGANIZATION COMMUNITY HEALTH CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 01/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | 10852 | SC | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 710852 | 05 | SC | MEDICAID |