Provider Demographics
NPI:1215499520
Name:CHARLOTTE COMMUNITY HEALTH CLINIC, INC.
Entity type:Organization
Organization Name:CHARLOTTE COMMUNITY HEALTH CLINIC, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-316-6561
Mailing Address - Street 1:5301 WILKINSON BLVD STE 1105
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-5455
Mailing Address - Country:US
Mailing Address - Phone:704-316-6562
Mailing Address - Fax:704-384-1977
Practice Address - Street 1:5301 WILKINSON BLVD STE 1105
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-5455
Practice Address - Country:US
Practice Address - Phone:704-316-6573
Practice Address - Fax:704-384-1977
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHARLOTTE COMMUNITY HEALTH CLINIC, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-04-04
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty