Provider Demographics
NPI:1063840296
Name:SOUTH CENTRAL PRIMARY CARE CENTER
Entity Type:Organization
Organization Name:SOUTH CENTRAL PRIMARY CARE CENTER
Other - Org Name:KIDS HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:B
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:JR
Authorized Official - Credentials:CEO
Authorized Official - Phone:229-468-9166
Mailing Address - Street 1:204 E 4TH ST
Mailing Address - Street 2:P O BOX 749
Mailing Address - City:OCILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31774-1539
Mailing Address - Country:US
Mailing Address - Phone:229-468-9166
Mailing Address - Fax:229-468-9188
Practice Address - Street 1:303 SHIRLEY AVE
Practice Address - Street 2:STE B
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533
Practice Address - Country:US
Practice Address - Phone:912-384-2474
Practice Address - Fax:912-384-4995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-25
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003140047AMedicaid