Provider Demographics
NPI:1639128176
Name:SOUTH COMMUNITY INC
Entity Type:Organization
Organization Name:SOUTH COMMUNITY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-293-8300
Mailing Address - Street 1:3095 KETTERING BLVD
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439
Mailing Address - Country:US
Mailing Address - Phone:937-293-8300
Mailing Address - Fax:937-534-1353
Practice Address - Street 1:3095 KETTERING BLVD
Practice Address - Street 2:
Practice Address - City:MORAINE
Practice Address - State:OH
Practice Address - Zip Code:45439
Practice Address - Country:US
Practice Address - Phone:937-293-8300
Practice Address - Fax:937-534-1353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0101261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0320870Medicaid
OHMC34-1000Medicaid
OH03676Medicare UPIN
9168323Medicare PIN
OHMC34-1000Medicaid