Provider Demographics
NPI:1972980621
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:M
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-857-0111
Mailing Address - Street 1:122 LATIMER ST
Mailing Address - Street 2:
Mailing Address - City:LATTA
Mailing Address - State:SC
Mailing Address - Zip Code:29565-1828
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:122 LATIMER ST
Practice Address - Street 2:
Practice Address - City:LATTA
Practice Address - State:SC
Practice Address - Zip Code:29565-1828
Practice Address - Country:US
Practice Address - Phone:843-857-0111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-01
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCFQC197Medicaid
SCFQC197Medicaid