Provider Demographics
NPI:1053065201
Name:CHARLOTTE COMMUNITY HEALTH CLINIC, INC.
Entity Type:Organization
Organization Name:CHARLOTTE COMMUNITY HEALTH CLINIC, INC.
Other - Org Name:SMITH FAMILY WELLNESS CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:STEFANI
Authorized Official - Middle Name:PRISCILIA
Authorized Official - Last Name:RUARTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-316-6573
Mailing Address - Street 1:8401 MEDICAL PLAZA DR STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-8702
Mailing Address - Country:US
Mailing Address - Phone:704-316-6561
Mailing Address - Fax:704-384-1977
Practice Address - Street 1:3622 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-5638
Practice Address - Country:US
Practice Address - Phone:704-316-6561
Practice Address - Fax:704-384-1977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-07
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)