Healthcare Provider Details

I. General information

NPI: 1215499520
Provider Name (Legal Business Name): CHARLOTTE COMMUNITY HEALTH CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2019
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5301 WILKINSON BLVD STE 1105
CHARLOTTE NC
28208-5455
US

IV. Provider business mailing address

5301 WILKINSON BLVD STE 1105
CHARLOTTE NC
28208-5455
US

V. Phone/Fax

Practice location:
  • Phone: 704-316-6573
  • Fax: 704-384-1977
Mailing address:
  • Phone: 704-316-6562
  • Fax: 704-384-1977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: LISA M HOLMES
Title or Position: COO
Credential:
Phone: 704-316-6561