Basic Information
| Provider Information | |||||||||
| NPI: | 1194710426 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REGENESIS ORGANIZATION COMMUNITY HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 5158 | ||||||||
| Address2: | |||||||||
| City: | SPARTANBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293045158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645822817 | ||||||||
| FaxNumber: | 8645822829 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 S. CHURCH STREET | ||||||||
| Address2: | |||||||||
| City: | SPARTANBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645822411 | ||||||||
| FaxNumber: | 8645827179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 05/18/2020 | ||||||||
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| AuthorizedOfficialLastName: | HUNTER | ||||||||
| AuthorizedOfficialFirstName: | MARLON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8645822817 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | FQC057 | 05 | SC | MEDICAID |