Healthcare Provider Details

I. General information

NPI: 1770616013
Provider Name (Legal Business Name): CAROLINA HEALTH CENTERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 06/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17124 HIGHWAY 72 W
WATERLOO SC
29384-5144
US

IV. Provider business mailing address

17124 HIGHWAY 72 W
WATERLOO SC
29384-5144
US

V. Phone/Fax

Practice location:
  • Phone: 864-819-4900
  • Fax: 864-819-3429
Mailing address:
  • Phone: 864-819-4900
  • Fax: 864-819-3429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MRS. LISA Y GILMER
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 864-941-8121