Provider Demographics
NPI:1750314183
Name:CURTIS V. COOPER PRIMARY HEALTH CARE, INC
Entity Type:Organization
Organization Name:CURTIS V. COOPER PRIMARY HEALTH CARE, INC
Other - Org Name:WESTSIDE URBAN HEALTH CENTER, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:EARLENE
Authorized Official - Middle Name:JOINER
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-527-1088
Mailing Address - Street 1:106 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31401-2917
Mailing Address - Country:US
Mailing Address - Phone:912-527-1000
Mailing Address - Fax:912-527-1153
Practice Address - Street 1:106 EAST BROAD STREET
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31401-2917
Practice Address - Country:US
Practice Address - Phone:912-527-1000
Practice Address - Fax:912-527-1153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10063424OtherAMERIGROUP
GA000463922BMedicaid
GA336180OtherWELLCARE
GA111809Medicare Oscar/Certification
GA10063424OtherAMERIGROUP