Provider Demographics
NPI:1871991059
Name:CAROLINA COMMUNITY MATERNITY CENTER
Entity type:Organization
Organization Name:CAROLINA COMMUNITY MATERNITY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/PARTNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSED MIDWIFE
Authorized Official - Phone:803-802-9494
Mailing Address - Street 1:2848 PLEASANT RD STE 101
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-9494
Mailing Address - Country:US
Mailing Address - Phone:803-802-9494
Mailing Address - Fax:877-802-1901
Practice Address - Street 1:2848 PLEASANT RD STE 101
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-9494
Practice Address - Country:US
Practice Address - Phone:803-802-9494
Practice Address - Fax:877-802-1901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-19
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCBC-0009176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1679704043Medicaid