Basic Information
| Provider Information | |||||||||
| NPI: | 1568914521 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BAKERSVILLE COMMUNITY MEDICAL CLINIC, INC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CELO HEALTH CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27 | ||||||||
| Address2: | |||||||||
| City: | BAKERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287050027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286882104 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 116 SEVEN MILE RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | BURNSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287148509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286754116 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2016 | ||||||||
| LastUpdateDate: | 07/07/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHELTON | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8286882104 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 07/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | NC | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1568914521 | 05 | NC | MEDICAID |