Provider Demographics
NPI:1629015755
Name:CARESOUTH CAROLINA, INC
Entity Type:Organization
Organization Name:CARESOUTH CAROLINA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-857-0111
Mailing Address - Street 1:PO BOX 1090
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29551-1090
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:204 PERRY WILEY WAY
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:SC
Practice Address - Zip Code:29709-5701
Practice Address - Country:US
Practice Address - Phone:843-623-5080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCFQC064Medicaid
SCCBP012Medicaid
SCCBP012Medicaid
SC1850Medicare PIN