Basic Information
| Provider Information | |||||||||
| NPI: | 1629015755 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARESOUTH CAROLINA, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1090 | ||||||||
| Address2: | |||||||||
| City: | HARTSVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295511090 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 204 PERRY WILEY WAY | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297095701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436235080 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 04/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | LEWIS | ||||||||
| AuthorizedOfficialFirstName: | ANN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8438570111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/16/2021 | ||||||||
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 | FQC064 | 05 | SC | MEDICAID | CBP012 | 05 | SC | MEDICAID |