NPIMap

Organization Active NPI

Rosa Clark Medical Center

Doing business as Rosa Clark Medical Clinic Association, Inc.

  • Federally Qualified Health Center (FQHC)
  • Seneca, SC
National Provider Identifier
1508903394
Registry record updated Nov 3, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
ROSA CLARK MEDICAL CENTER
Doing business as
Rosa Clark Medical Clinic Association, Inc.
Practice address
301 Memorial Dr
Seneca, SC 29672
Phone
(864) 882-4629
Fax
(864) 882-4478
NPI assigned
Jan 31, 2007
Last updated
Nov 3, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 3, 2023

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

Authorized official

Name
Jamie Shannon Lee
Title
Chief Financial Officer
Phone
(864) 614-5617

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary
Pharmacy 333600000X
Clinic Pharmacy 3336C0002X 3129 SC

Addresses

Primary practice location

301 Memorial Dr
Seneca, SC 29672

Mailing address

301 Memorial Dr
Seneca, SC 29672-9491
Phone (864) 614-5617

Other practice location 1

1608 E Main Street
Westminster, SC 29693
Phone (864) 882-4629

Other practice location 2

210 S Oak St
Seneca, SC 29678-3416
Phone (864) 882-4629

Other identifiers 1

IdentifierTypeStateIssuer
2125083OtherPK

Other names 1

  • Rosa Clark Medical Clinic Association, Inc. Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SC2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20160511000856 SC Part B Supplier - Clinic/Group Practice 2466741657 Receives reassigned benefits from 9 practitioners
Practice locations: Seneca, SC; Westminster, SC
O20170322001209 SC Part A Provider - Federally Qualified Health Center (FQHC) 2466741657 Practice locations: Seneca, SC

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1508903394. Details of each certification follow.

Federally qualified health center certification: CCN 421049

Legal name
ROSA CLARK MEDICAL CLINIC ASSOCIATION, INC
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 22, 2017
Last certification
Mar 22, 2017
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Dec 13, 1991 in SC
Enrollment address
301 Memorial Dr
Seneca, SC 29672-9491

Other NPIs with the same Medicare PAC ID 1

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
42D2127994Rosa Clark Medical Clinic301 Memorial Drive, Seneca, SC 29672Provider-performed microscopyMar 21, 2027

National Provider Directory

National Provider Directory
Tax ID family
Rosa Clark Medical Clinic Association Inc3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

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

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

Locations

210 S Oak St
Seneca, SC 29678
Phone (864) 614-5990

301 Memorial Dr
Ste C
Seneca, SC 29672

1608 E Main St
Westminster, SC 29693
Phone (864) 614-5617

Ownership & related parties

All disclosed owners & managing parties 2

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

NameRoleSinceShare
Rosa Clark Medical Clinic Association, Inc Organization, Seneca, SC Non-profit 5% Or Greater Direct Ownership Interest Dec 13, 1991 100%
Vicki Thompson Individual Corporate Director Mar 1, 2016
Operational/Managerial Control Mar 1, 2016

Owners & managing parties with NPI records 1

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

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Rosa Clark Medical Clinic IncWestminster, SC, CCN 421122 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%)
Other		 Apr 1, 2024
Jun 3, 2024

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 1

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 11

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.

NPI Registry JSON

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

{
    "created_epoch": "1170201600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1698969600000",
    "number": "1508903394",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "301 MEMORIAL DR",
            "city": "SENECA",
            "state": "SC",
            "postal_code": "296729491",
            "telephone_number": "864-614-5617",
            "fax_number": "864-882-4478"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "301 MEMORIAL DR",
            "city": "SENECA",
            "state": "SC",
            "postal_code": "29672",
            "telephone_number": "864-882-4629",
            "fax_number": "864-882-4478"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1608 E Main Street",
            "address_purpose": "LOCATION",
            "city": "Westminster",
            "state": "SC",
            "postal_code": "29693",
            "country_code": "US",
            "telephone_number": "864-882-4629",
            "fax_number": "864-882-4478",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "210 S Oak St",
            "address_purpose": "LOCATION",
            "city": "Seneca",
            "state": "SC",
            "postal_code": "296783416",
            "country_code": "US",
            "telephone_number": "864-882-4629",
            "fax_number": "864-882-4478",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "ROSA CLARK MEDICAL CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-31",
        "last_updated": "2023-11-03",
        "certification_date": "2023-11-02",
        "status": "A",
        "authorized_official_last_name": "LEE",
        "authorized_official_first_name": "JAMIE",
        "authorized_official_middle_name": "SHANNON",
        "authorized_official_title_or_position": "CHIEF FINANCIAL OFFICER",
        "authorized_official_telephone_number": "864-614-5617"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0002X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Clinic Pharmacy",
            "state": "SC",
            "license": "3129",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2125083",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Rosa Clark Medical Clinic Association, Inc.",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Rosa Clark Medical Clinic Association, Inc.",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Seneca, SC

Sources for this page

Verify at the official NPI Registry.