Provider Demographics
NPI:1437102449
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:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:S
Authorized Official - Last Name:NIXON
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:706-657-7575
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:706-657-7575
Mailing Address - Fax:706-657-6575
Practice Address - Street 1:13570 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:GA
Practice Address - Zip Code:30752-2012
Practice Address - Country:US
Practice Address - Phone:706-956-2665
Practice Address - Fax:706-657-5885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10057286OtherAMERIGROUP (GA MEDICAID)
GA336412OtherWELLCARE (GA MEDICAID MCO
GA000211956AMedicaid
=========OtherTRICARE
GA000211956AMedicaid
GAGRP593Medicare ID - Type UnspecifiedGA MEDICARE GROUP PROV #
GA10057286OtherAMERIGROUP (GA MEDICAID)