Provider Demographics
NPI:1639202922
Name:CAROLINA HEALTH CENTERS, INC.
Entity Type:Organization
Organization Name:CAROLINA HEALTH CENTERS, INC.
Other - Org Name:THE PENDERGRASS FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REVENUE CYCLE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:Y
Authorized Official - Last Name:GILMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-941-8121
Mailing Address - Street 1:93 S GREENWOOD AVE
Mailing Address - Street 2:PO BOX 389
Mailing Address - City:WARE SHOALS
Mailing Address - State:SC
Mailing Address - Zip Code:29692-1534
Mailing Address - Country:US
Mailing Address - Phone:864-456-7436
Mailing Address - Fax:864-456-2942
Practice Address - Street 1:85 S GREENWOOD AVE
Practice Address - Street 2:
Practice Address - City:WARE SHOALS
Practice Address - State:SC
Practice Address - Zip Code:29692-1534
Practice Address - Country:US
Practice Address - Phone:864-456-7436
Practice Address - Fax:864-456-2942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCFQC019Medicaid
SCFQC019Medicaid
SC=========011OtherBLUE CROSS PROVIDER NUMBE
SC=========005OtherTRICARE PROVIDER NUMBER
SC5540Medicare ID - Type UnspecifiedSC MEDICARE PROVIDER NUMB