Fetter Health Care Network Inc
Organization Active NPI Federally Qualified Health Center (FQHC) · Hollywood, SC
NPI 1386792976 · NPPES record last updated Oct 18, 2016
Key facts
- NPI
- 1386792976
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- FETTER HEALTH CARE NETWORK INC
- Practice address
- 5225 Highway 165
Hollywood, SC 29449-6144 - Phone
- (843) 889-2272
- Fax
- (843) 889-2274
- NPI assigned
- Jan 8, 2007
- Organization subpart
- No
Authorized official
- Name
- Mrs. Aretha Jones
- Title
- Executive Director
- Phone
- (843) 722-4112
Owners & managing parties with NPI records 3
-
Shantae James Jenkins, MD, PHD
-
Nicholas Shungu, M.D.
Owned or controlled facilities with NPI records 1
Other NPIs on the same Medicare enrollment 14
Other NPIs with the same Medicare PAC ID 14
Corporate family (same tax ID) 37
Practitioners 35
-
Caitlin Wells Briggs, APRN
-
Mary Elizabeth Creed, APRN, FNP-C
-
Richetta Deas, ANP-C
-
Charles Effiong, MD
-
Wakesha T Evans, PA-C
-
Christopher Fecek, MD, MS
-
Terri Olivia Fowler, F.N.P.
-
Anna Nicole Gray, FNP-BC
-
Pamela Sherl Johnson, FNP APRN
-
Dana Annette Laforte, APRN-FNP
-
Emily Ruth Pogue, MSN, APRN, AGACNP-BC
-
Lakosha T Wade, NP
-
Cilantay R Wilson, APRN
-
Dennis Tambe Besong, M.D.
-
Allahna Allybia Coggins, M.D.
-
Roynell Frank, FNP
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in SC
Federally qualified health center certification: CCN 421856
- Legal name
- FETTER HEALTH CARE NETWORK INC
- Doing business as
- HOLLYWOOD FAMILY HEALTH CENTER
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Aug 3, 1998
- Last certification
- Aug 3, 1998
- Ownership / control type
- For profit – partnership
- Most recent change of ownership
- Apr 1, 2008 (2 total)
- Organization structure
- Corporation · Non-profit
- Incorporated
- Apr 8, 1975 in SC
- Enrollment address
- 5225 Highway 165
Hollywood, SC 29449-6144
All disclosed owners & managing parties 11
| Name | Role | Since | Share |
|---|---|---|---|
| Shantae J Jenkins |
Corporate Officer |
Jan 1, 2014 | |
| W-2 Managing Employee |
Aug 31, 2015 | ||
| Alison McCullough |
Corporate Officer |
Jan 1, 2023 | |
| Nicholas P Shungu |
Corporate Officer |
Jan 1, 2023 | |
| Darlene E Wright |
Corporate Officer |
Jan 1, 2014 | |
| Enid B Jenkins |
Corporate Officer |
Jan 1, 2014 | |
| Shelli D Quenga |
Corporate Officer |
Jan 1, 2023 | |
| Aretha Powers |
Corporate Director |
Apr 11, 2016 | |
| W-2 Managing Employee |
Apr 11, 2016 | ||
| Sonya B Jones |
Corporate Officer |
Jan 1, 2014 | |
| Deborah C Williamson |
Corporate Officer |
Jan 1, 2014 | |
| Phalarma Freeman |
Corporate Officer |
Jan 1, 2014 | |
| Catherine Oconnor Durham |
Corporate Officer |
Jan 1, 2023 |
All facility ownership & control disclosures 1
| Facility | Type | Role | Since |
|---|---|---|---|
| Fetter Health Care Network Inc |
Federally qualified health center | Operational/Managerial Control (100%) | Sep 18, 2014 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20070507000192 | SC | Part B Supplier - Clinic/Group Practice | 9032215199 |
Receives reassigned benefits from 91 practitioners 14 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Walterboro, SC; Cross, SC; Summerville, SC; North Charleston, SC; N Charleston, SC; Charleston, SC; Johns Island, SC; Hollywood, SC |
| O20080819000386 | SC | Part a Provider - Federally Qualified Health Center (FQHC) | 9032215199 | Practice locations: Hollywood, SC |
National Provider Directory
- Tax ID family
- Fetter Health Care Network Inc
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
5225 Highway 165
Hollywood, SC 29449-6144
Mailing address
51 Nassau Street
Charleston, SC 29403-5513
Phone (843) 722-4112
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| FQC047 | Medicaid | SC |
Other names
- Fetter Health Care Network-Hollywood Site
Other providers in Hollywood, SC
- Mary Elizabeth Creed
- Marsha Gay Delavan
- Delta of Hollywood LLC
- Terri Donofrio
- Polly Jones Epstein
- Fetter Health Care Network Inc
- Fetter Health Care Network Inc
- Fetter Health Care Network, Inc.
- Fetter Health Care Network, Inc.
- Mae Helen Frazier
All providers in Hollywood, SC · Federally Qualified Health Center (FQHC) in South Carolina
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 18, 2016. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.