Provider Demographics
NPI:1265624548
Name:FOUR CORNERS PRIMARY CARE CENTERS INC
Entity type:Organization
Organization Name:FOUR CORNERS PRIMARY CARE CENTERS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:O
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-279-3140
Mailing Address - Street 1:5300 OAKBROOK PKWY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30093-2256
Mailing Address - Country:US
Mailing Address - Phone:770-279-3142
Mailing Address - Fax:770-234-5210
Practice Address - Street 1:5300 OAKBROOK PKWY
Practice Address - Street 2:SUITE 130
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30093-2256
Practice Address - Country:US
Practice Address - Phone:770-279-3142
Practice Address - Fax:770-234-5210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-10
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA162765396AMedicaid
GA11-1901Medicare PIN