1639664303 NPI number — SOUTH CENTRAL PRIMARY CARE CENTER, 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 1639664303 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:
1639664303
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:
PO BOX 749
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCILLA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31774-0749
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:
247 NORTHSIDE DR STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALDOSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-253-1206
Provider Business Practice Location Address Fax Number:
229-253-1209
Provider Enumeration Date:
06/26/2018

Additional Information

Authorized Official

Authorized Official Last Name:
TUCKER
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
B
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)





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