NPIMap

Organization Active NPI

Carolina Health Centers, Inc.

Doing business as Lakelands Family Practice

  • Family Medicine Physician
  • Waterloo, SC
National Provider Identifier
1770616013
Registry record updated Jun 21, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
CAROLINA HEALTH CENTERS, INC.
Doing business as
Lakelands Family Practice
Practice address
17124 Highway 72 W
Waterloo, SC 29384-5144
Phone
(864) 819-4900
Fax
(864) 819-3429
NPI assigned
Mar 14, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 21, 2010

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

Authorized official

Name
Mrs. Lisa Y Gilmer
Title
Practice Administrator
Phone
(864) 941-8121

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X Primary
Federally Qualified Health Center (FQHC) 261QF0400X

Addresses

Primary practice location

17124 Highway 72 W
Waterloo, SC 29384-5144

Mailing address

17124 Highway 72 W
Waterloo, SC 29384-5144
Phone (864) 819-4900

Other identifiers 1

IdentifierTypeStateIssuer
FQC058MedicaidSC

Other names 1

  • Lakelands Family Practice Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050214000851 SC Part A Provider - Federally Qualified Health Center (FQHC) 5496707804 Practice locations: Waterloo, SC
O20050825000437 SC Part B Supplier - Clinic/Group Practice 5496707804 Receives reassigned benefits from 37 practitioners
10 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Ridge Spring, SC; Waterloo, SC; Ware Shoals, SC; Saluda, SC; MC Cormick, SC; Greenwood, SC; Clinton, SC; Calhoun Falls, SC

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1770616013. Details of each certification follow.

Federally qualified health center certification: CCN 421894

Legal name
CAROLINA HEALTH CENTERS INC
Doing business as
LAKLEANDS FAMILY PRACTICE AND PEDIATRICS CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Apr 4, 2005
Last certification
Apr 4, 2005
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Jun 27, 1977 in SC
Enrollment address
17124 Highway 72 W
Waterloo, SC 29384-5144

Other NPIs with the same Medicare PAC ID 14

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

View all 14

Other NPIs on the same Medicare enrollment 10

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

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 16

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

NameRoleSinceShare
Christopher Scott Clem Individual Corporate OfficerCfo Jun 16, 2025
Bonnie Ramage Individual Corporate DirectorBoard Member Sep 26, 2022
Abby Banks Individual Corporate DirectorBoard Member Mar 27, 2017
Kimberly Kapetanakos Individual Corporate DirectorBoard Member Mar 27, 2017
Malcolm O'Neal Individual Corporate DirectorBoard Member Sep 29, 2014
Donna Hutchinson Individual Corporate DirectorBoard Member Oct 28, 2019
Miriam Ferguson Individual Corporate OfficerActing Ceo Jul 14, 2025 100%
W-2 Managing EmployeeActing Ceo Jul 14, 2025 100%
Johanna Bishop Individual Corporate DirectorBoard Member Jun 28, 2021
Mario Luna Individual Corporate DirectorBoard Member Sep 29, 2014
Rodriguis Brown Individual Corporate DirectorBoard Member Dec 7, 2021
Gail D Ferguson Individual Corporate DirectorBoard Member Mar 3, 1987
John Britt Individual Corporate OfficerChariman of Board Mar 25, 1985
Corporate DirectorChairman of Board Mar 25, 1985
Julian Gale Individual Corporate DirectorBoard Member Sep 26, 2022
Sojourner Jennings Individual Corporate DirectorBoard Member Dec 7, 2021
David Otabor Individual Corporate DirectorBoard Member Sep 26, 2022
Locke Eugene Simons Individual Corporate OfficerChief Medical Officer Jun 1, 2002

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 5

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": "1173830400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1277078400000",
    "number": "1770616013",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "17124 HIGHWAY 72 W",
            "city": "WATERLOO",
            "state": "SC",
            "postal_code": "293845144",
            "telephone_number": "864-819-4900",
            "fax_number": "864-819-3429"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "17124 HIGHWAY 72 W",
            "city": "WATERLOO",
            "state": "SC",
            "postal_code": "293845144",
            "telephone_number": "864-819-4900",
            "fax_number": "864-819-3429"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CAROLINA HEALTH CENTERS, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-14",
        "last_updated": "2010-06-21",
        "status": "A",
        "authorized_official_last_name": "GILMER",
        "authorized_official_first_name": "LISA",
        "authorized_official_middle_name": "Y",
        "authorized_official_title_or_position": "PRACTICE ADMINISTRATOR",
        "authorized_official_telephone_number": "864-941-8121",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "FQC058",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lakelands Family Practice",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Waterloo, SC

Sources for this page

Verify at the official NPI Registry.