MEDICARE: CARESOUTH CAROLINA, INC.

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	261QF0400X	Federally Qualified Health Center (FQHC)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780627943
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARESOUTH CAROLINA, INC.

Provider Business Mailing Address
First Line	:	PO BOX 1090
Second Line	:
City	:	HARTSVILLE
State	:	SC
Zip	:	29551-1090
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	103 KEMPER STREET
Second Line	:
City	:	LAKE VIEW
State	:	SC
Zip	:	29563
Country	:	US
Telephone Number	:	843-759-2189
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	ANN LEWIS
Credential	:
Telephone Number	:	843-857-0111

Provider Enumeration Date	:	06/14/2006
Last Update Date	:	09/04/2007

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