Caresouth Carolina Inc
Organization Active NPI Federally Qualified Health Center (FQHC) · Bennettsville, SC
NPI 1639458672 · NPPES record last updated Mar 21, 2012
Key facts
- NPI
- 1639458672
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Federally Qualified Health Center (FQHC) 261QF0400X
- Legal business name
- CARESOUTH CAROLINA INC
- Practice address
- 210 W Main St
Bennettsville, SC 29512-3122 - Phone
- (843) 479-1200
- Fax
- (843) 479-1230
- NPI assigned
- Aug 9, 2011
- Organization subpart
- No
Authorized official
- Name
- Ann M Lewis
- Title
- Ceo
- Phone
- (843) 857-0111
Other NPIs on the same Medicare enrollment 11
Other NPIs with the same Medicare PAC ID 11
Corporate family (same tax ID) 25
Practitioners 72
-
Katelon Marie Smith, FNP-C
-
Heather Deanna Alexander, FNP-C
-
Jeri Lynn Andrews, APRN, FNP-BC
-
Leandria Nichelle Bivens, LISW-CP
-
Jocelyn Boyer, DEEDEE
-
Jeffrey Michael Brock, M.D.
-
Elizabeth Brown, LISW-CP
-
Bradley D Burgess, M.A..
-
Nicole Hardee Chapman, LISW-CP
-
Amy Jennifer Cook, LISW-CP
-
Angela Council, FNP
-
Cindy Crittendon, DO
-
Johnathan Charles Davis, D.C.
-
James Bernard Fleming, M.D.
-
Ludie Kathleen Floyd-Moore, LISW-CP
-
Kirsten Forinash, LMSW
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 42D1024216 | Caresouth Carolina Pediatrics | Certificate of waiver | Apr 5, 2028 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in SC
Federally qualified health center certification: CCN 421948
- Legal name
- CARESOUTH CAROLINA INC.
- Certification status
- Active
- Provider type (POS)
- Federally qualified health center
- Participating since
- Nov 17, 2011
- Last certification
- Nov 17, 2011
- Ownership / control type
- For profit – corporation
- Organization structure
- Corporation · Non-profit
- Incorporated
- Apr 5, 1978 in SC
- Enrollment address
- 210 West Main Street
Bennettsville, SC 29512-1076
All disclosed owners & managing parties 13
| Name | Role | Since | Share |
|---|---|---|---|
| Mary J Garvin |
Corporate Officer |
Apr 7, 1978 | |
| Ennis R Bryant |
Corporate Officer |
Jan 1, 1992 | |
| Flossie W Bartell |
Corporate Officer |
Jun 26, 2003 | |
| Teresa Gainey |
Corporate Officer |
Dec 19, 2019 | |
| Ann Marie Lewis |
Corporate Officer |
Apr 5, 1978 | |
| Corporate Director |
Apr 5, 1978 | ||
| Operational/Managerial Control |
Apr 5, 1978 | ||
| Trudy Drawhorn |
Corporate Officer |
Jul 27, 2017 | |
| Earnestine S Powe |
Corporate Officer |
Jan 1, 1984 | |
| Patricia M Henegan |
Corporate Officer | Jul 27, 2017 | |
| Dorothy S Joyner |
Corporate Officer |
Jan 1, 1996 | |
| Gene T Harper |
Corporate Officer |
Oct 16, 2023 | |
| Bonnie M Seals |
Corporate Officer |
Jan 1, 1996 | |
| Mary D Legrant |
Corporate Officer |
Jan 1, 1996 | |
| Jay S Hodge |
Corporate Officer |
Jan 1, 1998 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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… |
| O20110923000018 | SC | Part a Provider - Federally Qualified Health Center (FQHC) | 1052221314 | Practice locations: Bennettsville, SC |
National Provider Directory
- Tax ID family
- Caresouth Carolina Inc
Locations
3080 Highway 15-401 E
Mc Coll, SC 29570
Phone (843) 523-5751
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician |
208000000X | |||
| Federally Qualified Health Center (FQHC) | 261QF0400X | Yes |
Addresses
Primary practice location
210 W Main St
Bennettsville, SC 29512-3122
Mailing address
PO Box 1090
Hartsville, SC 29551-1090
Phone (843) 857-0111
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| FQC093 | Medicaid | SC |
Other providers in Bennettsville, SC
- Rufus Haynes Cain
- Winninah Camania Calderon
- Zenaida Candela
- Caresouth
- Caresouth Carolina Inc
- Caresouth Carolina, Inc
- Patricia Carlin
- Carolina Regional Associates of Pathology
- Georgette Chavis
- Brittany Cheek
All providers in Bennettsville, 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 Mar 21, 2012. 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.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.