1295094340 NPI number — SOUTH CENTRAL PRIMARY CARE CENTER, INC

Table of content: (NPI 1295094340)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295094340 NPI number — SOUTH CENTRAL PRIMARY CARE CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH CENTRAL PRIMARY CARE CENTER, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295094340
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
204 E 4TH ST
Provider Second Line Business Mailing Address:
P O BOX 749
Provider Business Mailing Address City Name:
OCILLA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31774-1421
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-468-9166
Provider Business Mailing Address Fax Number:
229-468-9188

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
299 W BENJAMIN HILL DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
FITZGERALD
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31750
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-423-5437
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/10/2012

Additional Information

Authorized Official

Authorized Official Last Name:
TUCKER
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
BONDS
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
229-468-9166

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0003124446A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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