Provider Demographics
NPI:1558445742
Name:SOUTH CENTRAL PRIMARY CARE CENTER, INC
Entity Type:Organization
Organization Name:SOUTH CENTRAL PRIMARY CARE CENTER, INC
Other - Org Name:SOUTH CENTRAL FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:B
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:229-468-9166
Mailing Address - Street 1:204 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:OCILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31774-1539
Mailing Address - Country:US
Mailing Address - Phone:229-468-9166
Mailing Address - Fax:229-468-9188
Practice Address - Street 1:640 MAIN ST N
Practice Address - Street 2:
Practice Address - City:PEARSON
Practice Address - State:GA
Practice Address - Zip Code:31642
Practice Address - Country:US
Practice Address - Phone:912-544-4569
Practice Address - Fax:912-422-3180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000611663FMedicaid
GA000611663FMedicaid
GA111899Medicare PIN