Healthcare Provider Details

I. General information

NPI: 1285461269
Provider Name (Legal Business Name): PRIMARY HEALTH CARE CENTER OF DADE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2024
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4038 E HIGHWAY 136
LA FAYETTE GA
30728-6041
US

IV. Provider business mailing address

13570 N MAIN ST
TRENTON GA
30752-2012
US

V. Phone/Fax

Practice location:
  • Phone: 706-866-5520
  • Fax: 706-657-2958
Mailing address:
  • Phone: 706-956-2665
  • Fax: 706-657-2958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: AMY BUFFINGTON
Title or Position: CREDENTIALING DIRECTOR
Credential:
Phone: 706-620-4494