Healthcare Provider Details

I. General information

NPI: 1649915216
Provider Name (Legal Business Name): CAROLINA CHILDREN'S CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2022
Last Update Date: 01/30/2023
Certification Date: 10/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 VILLAGE CREEK DR
BOILING SPRINGS SC
29316-5387
US

IV. Provider business mailing address

316 VILLAGE CREEK DR
BOILING SPRINGS SC
29316-5387
US

V. Phone/Fax

Practice location:
  • Phone: 864-327-9003
  • Fax:
Mailing address:
  • Phone: 864-327-9003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DAVID 'CARSON' MOORE
Title or Position: OWNER/AUTHORIZED OFFICIAL
Credential:
Phone: 843-324-7575