Provider Demographics
NPI:1376207985
Name:SOUTH CENTRAL PRIMARY CARE CENTER, INC
Entity Type:Organization
Organization Name:SOUTH CENTRAL PRIMARY CARE CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BONDS
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-468-9166
Mailing Address - Street 1:PO BOX 749
Mailing Address - Street 2:
Mailing Address - City:OCILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31774-0749
Mailing Address - Country:US
Mailing Address - Phone:229-468-9166
Mailing Address - Fax:229-468-9188
Practice Address - Street 1:3308 GREYSTONE WAY
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-1096
Practice Address - Country:US
Practice Address - Phone:229-468-9166
Practice Address - Fax:229-468-9188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-29
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)