Provider Demographics
NPI:1316794639
Name:ROSA CLARK MEDICAL CENTER
Entity type:Organization
Organization Name:ROSA CLARK MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:SHANNON
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-973-7391
Mailing Address - Street 1:301 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29672-9491
Mailing Address - Country:US
Mailing Address - Phone:864-882-4664
Mailing Address - Fax:864-614-5006
Practice Address - Street 1:1608 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:SC
Practice Address - Zip Code:29693
Practice Address - Country:US
Practice Address - Phone:864-973-7391
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROSA CLARK MEDICAL CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-05-03
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty