Basic Information
| Provider Information | |||||||||
| NPI: | 1487053021 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FETTER HEALTH CARE NETWORK INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FETTER HEALTH CARE NETWORK-JOHNS ISLAND SITE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 51 NASSAU ST | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294035513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437224112 | ||||||||
| FaxNumber: | 8435778960 | ||||||||
| Practice Location | |||||||||
| Address1: | 3627 MAYBANK HWY | ||||||||
| Address2: | |||||||||
| City: | JOHNS ISLAND | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294554825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436280284 | ||||||||
| FaxNumber: | 8435599912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2014 | ||||||||
| LastUpdateDate: | 10/18/2016 | ||||||||
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| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | ARETHA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8437224112 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | FQC182 | 05 | SC | MEDICAID |