Healthcare Provider Details

I. General information

NPI: 1588592307
Provider Name (Legal Business Name): ROSA CLARK MEDICAL CLINIC ASSOCIATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 DEVELOPMENT DR
WEST UNION SC
29696-2651
US

IV. Provider business mailing address

301 MEMORIAL DR
SENECA SC
29672-9491
US

V. Phone/Fax

Practice location:
  • Phone: 864-882-4664
  • Fax:
Mailing address:
  • Phone: 864-614-5617
  • Fax: 864-614-5617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MISS JAMIE SHANNON LEE
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 864-614-5617