1356715452 NPI number — PRIMARY HEALTH CARE CENTER OF DADE, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356715452 NPI number — PRIMARY HEALTH CARE CENTER OF DADE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIMARY HEALTH CARE CENTER OF DADE, 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:
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:
1356715452
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13570 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRENTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30752-2012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-956-2665
Provider Business Mailing Address Fax Number:
706-657-2958

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
87 S BURNT MILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA FAYETTE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30728-4263
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-620-4494
Provider Business Practice Location Address Fax Number:
706-657-2958
Provider Enumeration Date:
11/30/2015

Additional Information

Authorized Official

Authorized Official Last Name:
ALLEN
Authorized Official First Name:
DIANA
Authorized Official Middle Name:
U
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
706-620-4494

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)





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