Provider Demographics
NPI:1922301472
Name:J.C. LEWIS PRIMARY HEALTHCARE CENTER, INC
Entity Type:Organization
Organization Name:J.C. LEWIS PRIMARY HEALTHCARE CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RENA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-721-6701
Mailing Address - Street 1:5 MALL ANX
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-4738
Mailing Address - Country:US
Mailing Address - Phone:912-721-6705
Mailing Address - Fax:912-495-8881
Practice Address - Street 1:5 MALL ANX
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-4738
Practice Address - Country:US
Practice Address - Phone:912-721-6701
Practice Address - Fax:912-495-8881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-06
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003110256AMedicaid
GA003156658AMedicaid
GA003104809AMedicaid
GA003135130AMedicaid
GA003122845AMedicaid
GA003122855AMedicaid