MEDICARE: COMMUNITY CENTRAL CARES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1518732536
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY CENTRAL CARES LLC

Provider Business Mailing Address
First Line	:	253 MONARCH CREEK LANE
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28206
Country	:	US
Telephone Number	:	980-286-7950
Fax Number	:

Provider Business Practice Location Address
First Line	:	5801 N MAIN ST STE D
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29203-6224
Country	:	US
Telephone Number	:	980-286-7950
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	VIRGINIA ROSLYN HUMPHRIES
Credential	:
Telephone Number	:	980-286-7950

Provider Enumeration Date	:	11/20/2023
Last Update Date	:	11/20/2023

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