NPIMap

Organization Active NPI

Charlotte Community Health Clinic, Inc.

  • Federally Qualified Health Center (FQHC)
  • Charlotte, NC
National Provider Identifier
1053065201
Registry record updated Aug 15, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
CHARLOTTE COMMUNITY HEALTH CLINIC, INC.
Practice address
3622 Central Ave
Charlotte, NC 28205-5638
Phone
(704) 316-6561
Fax
(704) 384-1977
NPI assigned
Feb 7, 2022
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 15, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Stefani Priscilia Ruarte
Title
Credentialing Coordinator
Phone
(704) 316-6573

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

3622 Central Ave
Charlotte, NC 28205-5638

Mailing address

8401 Medical Plaza Dr Ste 300
Charlotte, NC 28262-8702
Phone (704) 316-6561

Other names 1

  • Smith Family Wellness Clinic Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20150626001703 NC Part B Supplier - Clinic/Group Practice 0840502274 Receives reassigned benefits from 32 practitioners
5 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Charlotte, NC
O20230518001415 NC Part A Provider - Federally Qualified Health Center (FQHC) 0840502274 Practice locations: Charlotte, NC

Federally qualified health center certification: CCN 861138

Legal name
CHARLOTTE COMMUNITY HEALTH CLINIC, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
May 18, 2023
Last certification
May 18, 2023
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Oct 30, 2001 in NC
Enrollment address
3622 Central Ave
Charlotte, NC 28205-5638

Other NPIs with the same Medicare PAC ID 4

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 5

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Charlotte Community Health Clinic Inc6 organizations share this tax ID, including this one

Other organizations with this tax ID 5

Organizations that report the same tax identification number in the National Provider Directory.

Locations

5301 Wilkinson Blvd
Charlotte, NC 28208
Phone (704) 316-6561

3622 Central Ave
Charlotte, NC 28205
Phone (704) 316-6561

Ownership & related parties

All disclosed owners & managing parties 17

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Jose' Portillo-Gamero Individual Other Oct 12, 2020
Marvin R Chiddick Individual Other Jan 10, 2022
Daniel Wall Individual Other Oct 4, 2021
Tania Archer Individual Other Jun 6, 2022
Michella Palmer Individual Other Dec 4, 2017
Ruth Perez Individual Other Dec 11, 2017
Latoinga L Sass Individual Other Feb 1, 2016
Francois Moukete Individual Other Jun 6, 2016
Stefani P Ruarte Individual Corporate OfficerBilling and Coding Specialist Jan 19, 2019
Denise Colter Individual Other Jun 3, 2019
Andrew P Das Individual Other Oct 1, 2014
Robin Canne Individual Other Feb 13, 2020
Jerome E Williams Individual Other Oct 7, 2017
Camille Grimsley Individual Other Feb 10, 2020
Carolyn Allison Individual Corporate DirectorCeo Jun 1, 2016
W-2 Managing EmployeeCeo Jun 1, 2016
Herbert W Clegg Individual Other Jun 1, 2013
Melida Baldera Individual Other May 4, 2020

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1644192000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1660521600000",
    "number": "1053065201",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8401 MEDICAL PLAZA DR STE 300",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282628702",
            "telephone_number": "704-316-6561",
            "fax_number": "704-384-1977"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3622 CENTRAL AVE",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282055638",
            "telephone_number": "704-316-6561",
            "fax_number": "704-384-1977"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHARLOTTE COMMUNITY HEALTH CLINIC, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-02-07",
        "last_updated": "2022-08-15",
        "certification_date": "2022-08-15",
        "status": "A",
        "authorized_official_last_name": "RUARTE",
        "authorized_official_first_name": "STEFANI",
        "authorized_official_middle_name": "PRISCILIA",
        "authorized_official_title_or_position": "CREDENTIALING COORDINATOR",
        "authorized_official_telephone_number": "704-316-6573"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Smith Family Wellness Clinic",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "Smith Family Wellness Clinic",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Charlotte, NC

Sources for this page

Verify at the official NPI Registry.