Provider Demographics
NPI:1184841942
Name:THE CHILDREN'S CLINIC
Entity Type:Organization
Organization Name:THE CHILDREN'S CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CARMINA
Authorized Official - Middle Name:C
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:803-289-5437
Mailing Address - Street 1:1228 COLONIAL COMMONS
Mailing Address - Street 2:SUITE 231
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29720-6233
Mailing Address - Country:US
Mailing Address - Phone:803-289-5437
Mailing Address - Fax:803-289-5440
Practice Address - Street 1:1228 COLONIAL COMMONS
Practice Address - Street 2:SUITE 231
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-6233
Practice Address - Country:US
Practice Address - Phone:803-289-5437
Practice Address - Fax:803-289-5440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC202300261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC202300Medicaid