Provider Demographics
NPI:1841432044
Name:SCREVEN COUNTY FAMILY HEALTH CENTER, LLC
Entity Type:Organization
Organization Name:SCREVEN COUNTY FAMILY HEALTH CENTER, LLC
Other - Org Name:OPTIM PRIMARY CARE - SYLVANIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SECRETARY OF SCREVEN COUNTY HOSPITA
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GUENTHNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-627-8247
Mailing Address - Street 1:210 EAST DERENNE AVENUE
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405
Mailing Address - Country:US
Mailing Address - Phone:912-644-1626
Mailing Address - Fax:912-644-5260
Practice Address - Street 1:105 ROCKY FORD RD
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:GA
Practice Address - Zip Code:30467-2027
Practice Address - Country:US
Practice Address - Phone:912-564-7133
Practice Address - Fax:912-564-2617
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SCREVEN COUNTY FAMILY HEALTH CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-02
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021262207Q00000X
GA261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty