Provider Demographics
NPI:1790974293
Name:26KC CENTER FOR FAMILY MEDICINE
Entity Type:Organization
Organization Name:26KC CENTER FOR FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNEDY
Authorized Official - Middle Name:KELECHI
Authorized Official - Last Name:OKERE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-826-3373
Mailing Address - Street 1:800 TOWNE PARK DR
Mailing Address - Street 2:SUIT 400, P.O .BOX 1599
Mailing Address - City:RINCON
Mailing Address - State:GA
Mailing Address - Zip Code:31326-5156
Mailing Address - Country:US
Mailing Address - Phone:912-308-8799
Mailing Address - Fax:
Practice Address - Street 1:800 TOWNE PARK DR
Practice Address - Street 2:SUIT 400,
Practice Address - City:RINCON
Practice Address - State:GA
Practice Address - Zip Code:31326-5156
Practice Address - Country:US
Practice Address - Phone:912-826-3373
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-20
Last Update Date:2009-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA50331261Q00000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000923062EMedicaid
GA000923062EMedicaid
GA511I080090Medicare PIN