MEDICARE: PRIMARY HEALTH CARE CENTER OF DADE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1952723298
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIMARY HEALTH CARE CENTER OF DADE, INC.

Provider Business Mailing Address
First Line	:	13570 N MAIN ST
Second Line	:
City	:	TRENTON
State	:	GA
Zip	:	30752-2012
Country	:	US
Telephone Number	:	706-657-7575
Fax Number	:	706-657-2958

Provider Business Practice Location Address
First Line	:	118 E GIRARD AVE
Second Line	:
City	:	CEDARTOWN
State	:	GA
Zip	:	30125-2778
Country	:	US
Telephone Number	:	706-866-8820
Fax Number	:	706-866-5502

Authorized Official
Title or Position	:	CEO
Name	:	DIANA U ALLEN
Credential	:
Telephone Number	:	706-996-8251

Provider Enumeration Date	:	01/06/2014
Last Update Date	:	04/07/2014

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