NPIMap

Organization Active NPI

Caresouth Carolina, Inc

  • Federally Qualified Health Center (FQHC)
  • Chesterfield, SC
National Provider Identifier
1629015755
Registry record updated Jul 21, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
CARESOUTH CAROLINA, INC
Practice address
204 Perry Wiley Way
Chesterfield, SC 29709-5701
Phone
(843) 623-5080
NPI assigned
May 31, 2006
Last updated
Jul 21, 2026By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 21, 2026

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

Authorized official

Name
Ann Lewis
Title
Ceo
Phone
(843) 857-0111

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Dental Clinic/Center 261QD0000X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

204 Perry Wiley Way
Chesterfield, SC 29709-5701

Mailing address

PO Box 1090
Hartsville, SC 29551-1090

Other identifiers 2

IdentifierTypeStateIssuer
FQC064MedicaidSC
CBP012MedicaidSC

Electronic endpoints 1

TypeEndpointUseAffiliation
Other URL https://www.medfusion.net/caresouthcarolina-24591/portal/#/user/login

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040511000280 SC Part B Supplier - Clinic/Group Practice 1052221314 Receives reassigned benefits from 95 practitioners
17 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Society Hill, SC; MC Coll, SC; Latta, SC; Lake View, SC; Hartsville, SC; Dillon, SC; Chesterfield, SC; Cheraw, SC…
O20041217000272 SC Part A Provider - Federally Qualified Health Center (FQHC) 1052221314 Practice locations: Chesterfield, SC

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1629015755. Details of each certification follow.

Federally qualified health center certification: CCN 421893

Legal name
CARESOUTH CAROLINA INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Feb 10, 2005
Last certification
Feb 10, 2005
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Apr 5, 1978 in SC
Enrollment address
204 Perry Wiley Way
Chesterfield, SC 29709

Other NPIs with the same Medicare PAC ID 11

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

Other NPIs on the same Medicare enrollment 11

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

National Provider Directory

National Provider Directory
Tax ID family
Caresouth Carolina Inc26 organizations share this tax ID, including this one

Other organizations with this tax ID 25

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

View all 25

Locations

500 West Blvd
Chesterfield, SC 29709
Phone (843) 623-3183

Ownership & related parties

All disclosed owners & managing parties 13

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

NameRoleSinceShare
Mary J Garvin Individual Corporate OfficerBoard Member Apr 7, 1978
Ennis R Bryant Individual Corporate DirectorBoard Member Jan 1, 1992
Flossie W Bartell Individual Corporate DirectorBoard Member Jun 26, 2003
Teresa Gainey Individual Corporate OfficerBoard Member Dec 19, 2019
Ann Marie Lewis Individual Corporate OfficerCeo Apr 5, 1978
W-2 Managing EmployeeCeo Apr 5, 1978
Trudy Drawhorn Individual Corporate OfficerBoard Member Jul 27, 2017
Earnestine S Powe Individual Corporate DirectorBoard Member Jan 1, 1984
Patricia M Henegan Individual Corporate OfficerBoard Member Jul 27, 2017
Dorothy S Joyner Individual Corporate DirectorBoard Member Jan 1, 1996
Gene T Harper Individual OtherBoard Member Oct 16, 2023
Bonnie M Seals Individual Corporate DirectorBoard Member Jan 1, 1996
Mary D Legrant Individual Corporate DirectorBoard Director Jan 1, 1996
Jay S Hodge Individual Corporate DirectorBoard Member Jan 1, 1998

Practitioners & affiliated clinicians

Practitioners 10

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": "1149033600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1784592000000",
    "number": "1629015755",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1090",
            "city": "HARTSVILLE",
            "state": "SC",
            "postal_code": "295511090"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "204 PERRY WILEY WAY",
            "city": "CHESTERFIELD",
            "state": "SC",
            "postal_code": "297095701",
            "telephone_number": "843-623-5080"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CARESOUTH CAROLINA, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-31",
        "last_updated": "2026-07-21",
        "certification_date": "2026-07-21",
        "status": "A",
        "authorized_official_last_name": "LEWIS",
        "authorized_official_first_name": "ANN",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "843-857-0111"
    },
    "taxonomies": [
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "FQC064",
            "state": "SC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "CBP012",
            "state": "SC"
        }
    ],
    "endpoints": [
        {
            "endpointType": "OTHERS",
            "endpointTypeDescription": "Other URL",
            "endpoint": "https://www.medfusion.net/caresouthcarolina-24591/portal/#/user/login",
            "affiliation": "N",
            "endpointDescription": "Patient Portal",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "Patietn Portal",
            "address_1": "204 Perry Wily Way",
            "city": "Chesterfield",
            "state": "SC",
            "country_code": "US",
            "postal_code": "297091402",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Chesterfield, SC

Sources for this page

Verify at the official NPI Registry.