Provider Demographics
NPI:1235648817
Name:FOUR CORNERS PRIMARY CARE CENTERS, INC.
Entity Type:Organization
Organization Name:FOUR CORNERS PRIMARY CARE CENTERS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-279-3141
Mailing Address - Street 1:5300 OAKBROOK PKWY STE 130
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-2261
Mailing Address - Country:US
Mailing Address - Phone:770-279-3144
Mailing Address - Fax:
Practice Address - Street 1:5300 OAKBROOK PKWY STE 130
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-2261
Practice Address - Country:US
Practice Address - Phone:770-279-3144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOUR CORNERS PRIMARY CARE CENTERS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHRE010360333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy