Provider Demographics
NPI:1295094340
Name:SOUTH CENTRAL PRIMARY CARE CENTER, INC
Entity type:Organization
Organization Name:SOUTH CENTRAL PRIMARY CARE CENTER, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BONDS
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-468-9166
Mailing Address - Street 1:204 E 4TH ST
Mailing Address - Street 2:P O BOX 749
Mailing Address - City:OCILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31774-1421
Mailing Address - Country:US
Mailing Address - Phone:229-468-9166
Mailing Address - Fax:229-468-9188
Practice Address - Street 1:299 W BENJAMIN HILL DR
Practice Address - Street 2:SUITE A
Practice Address - City:FITZGERALD
Practice Address - State:GA
Practice Address - Zip Code:31750
Practice Address - Country:US
Practice Address - Phone:229-423-5437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-10
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0003124446AMedicaid