Provider Demographics
NPI:1417027244
Name:FETTER HEALTH CARE NETWORK, INC
Entity Type:Organization
Organization Name:FETTER HEALTH CARE NETWORK, INC
Other - Org Name:FRANKLIN C FETTER FAMILY HEALTH CENTER-HOSPITALIZATION
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:REUBEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:PETTIFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-722-4112
Mailing Address - Street 1:51 NASSAU ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403-5513
Mailing Address - Country:US
Mailing Address - Phone:843-722-4112
Mailing Address - Fax:843-577-8960
Practice Address - Street 1:51 NASSAU ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29403-5513
Practice Address - Country:US
Practice Address - Phone:843-722-4112
Practice Address - Fax:843-577-8960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCBP015Medicaid
SC6464Medicare PIN