Provider Demographics
NPI:1356682959
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:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-279-3142
Mailing Address - Street 1:5030 GEORGIA BELLE CT
Mailing Address - Street 2:SUITE 2066
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-2667
Mailing Address - Country:US
Mailing Address - Phone:770-279-3142
Mailing Address - Fax:770-234-5210
Practice Address - Street 1:175 GWINNETT DR
Practice Address - Street 2:SUITE 213
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8444
Practice Address - Country:US
Practice Address - Phone:770-279-3142
Practice Address - Fax:770-234-5210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-06
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)