Provider Demographics
NPI:1639664303
Name:SOUTH CENTRAL PRIMARY CARE CENTER, INC
Entity Type:Organization
Organization Name:SOUTH CENTRAL PRIMARY CARE CENTER, INC
Other - Org Name:NORTHSIDE FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
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: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 1:247 NORTHSIDE DR STE B
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602
Practice Address - Country:US
Practice Address - Phone:229-253-1206
Practice Address - Fax:229-253-1209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-26
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)