NPIMap

Organization Active NPI

Charlotte Community Health Clinic, Inc.

  • Federally Qualified Health Center (FQHC)
  • Charlotte, NC
National Provider Identifier
1073367249
Registry record updated May 1, 2024
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
3400 Shamrock Dr
Charlotte, NC 28215-3212
Phone
(704) 316-6561
Fax
(704) 384-1977
NPI assigned
Apr 15, 2024
Last updated
May 1, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
CHARLOTTE COMMUNITY HEALTH CLINIC, INC.As reported in NPPES

NPPES NPI Registry

Updated by the provider on May 1, 2024

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

Authorized official

Name
Lisa M Holmes
Title
Chief Operations Officer
Phone
(704) 316-6561

Specialties & licenses 1

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

Addresses

Primary practice location

3400 Shamrock Dr
Charlotte, NC 28215-3212

Mailing address

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

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
O20240820003222 NC Part A Provider - Federally Qualified Health Center (FQHC) 0840502274 Practice locations: Charlotte, NC

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1073367249. Details of each certification follow.

Federally qualified health center certification: CCN B61053

Legal name
CHARLOTTE COMMUNITY HEALTH CLINIC, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Aug 20, 2024
Last certification
Aug 20, 2024
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jun 27, 2001 in NC
Enrollment address
3400 Shamrock Dr
Charlotte, NC 28215-3212

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 Inc7 organizations share this tax ID, including this one
Part of
Charlotte Community Health Clinic Inc

Other organizations with this tax ID 6

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

Locations

3400 Shamrock Dr
Charlotte, NC 28215
Phone (704) 316-6561

5301 Wilkinson Blvd
Ste 1105
Charlotte, NC 28208
Phone (704) 316-6573

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 OtherBoard Member Oct 12, 2020
Marvin R Chiddick Individual OtherBoard Member Jan 10, 2022
Daniel Wall Individual OtherBoard Member Oct 4, 2021
Tania Archer Individual OtherBoard Member Jun 6, 2022
Michella Palmer Individual OtherBoard Member Dec 4, 2017
Ruth Perez Individual OtherBoard Member Dec 11, 2017
Latoinga L Sass Individual OtherBoard Member Jun 1, 2016
Francois Moukete Individual OtherBoard Member Jun 1, 2016
Stefani P Ruarte Individual Corporate OfficerLead Revenue Cycle Specialist Jan 19, 2019
Denise Colter Individual OtherBoard Member Jun 3, 2019
Andrew P Das Individual OtherBoard Member Oct 1, 2014
Robin Canne Individual OtherBoard Member Feb 13, 2020
Jerome E Williams Individual OtherBoard Member Oct 7, 2017
Camille Grimsley Individual OtherBoard Member Feb 10, 2020
Carolyn Allison Individual Corporate OfficerCeo Jun 1, 2016
Corporate DirectorCeo Jun 1, 2016
W-2 Managing EmployeeCeo Jun 1, 2016
Operational/Managerial ControlCeo Jun 1, 2016
Herbert W Clegg Individual OtherBoard Member Jun 1, 2023
Melida Baldera Individual OtherBoard Member 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 27

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 27

NPI Registry JSON

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

{
    "created_epoch": "1713139200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1714521600000",
    "number": "1073367249",
    "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": "3400 SHAMROCK DR",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282153212",
            "telephone_number": "704-316-6561",
            "fax_number": "704-384-1977"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHARLOTTE COMMUNITY HEALTH CLINIC, INC.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CHARLOTTE COMMUNITY HEALTH CLINIC, INC.",
        "enumeration_date": "2024-04-15",
        "last_updated": "2024-05-01",
        "certification_date": "2024-05-01",
        "status": "A",
        "authorized_official_last_name": "HOLMES",
        "authorized_official_first_name": "LISA",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "CHIEF OPERATIONS OFFICER",
        "authorized_official_telephone_number": "704-316-6561"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Charlotte, NC

Sources for this page

Verify at the official NPI Registry.