Healthcare Provider Details

I. General information

NPI: 1609640861
Provider Name (Legal Business Name): FAMILY HEALTH CENTERS VILLAGE PARK DRIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2023
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 VILLAGE PARK DR
ORANGEBURG SC
29118-2457
US

IV. Provider business mailing address

1760 VILLAGE PARK DR
ORANGEBURG SC
29118-2457
US

V. Phone/Fax

Practice location:
  • Phone: 803-531-6900
  • Fax:
Mailing address:
  • Phone: 803-531-6900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: DR. STAN WARDLAW
Title or Position: CEO
Credential:
Phone: 803-531-6900