Provider Demographics
NPI:1235505678
Name:PRIMARY HEALTH CARE CENTER OF DADE, INC.
Entity Type:Organization
Organization Name:PRIMARY HEALTH CARE CENTER OF DADE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-620-4494
Mailing Address - Street 1:13570 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:GA
Mailing Address - Zip Code:30752-2012
Mailing Address - Country:US
Mailing Address - Phone:706-956-2665
Mailing Address - Fax:706-657-2958
Practice Address - Street 1:87 S BURNT MILL RD
Practice Address - Street 2:
Practice Address - City:LA FAYETTE
Practice Address - State:GA
Practice Address - Zip Code:30728-4263
Practice Address - Country:US
Practice Address - Phone:706-620-4494
Practice Address - Fax:706-620-2379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-20
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)