Healthcare Provider Details

I. General information

NPI: 1740028117
Provider Name (Legal Business Name): PRIMECARE ABA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2024
Last Update Date: 07/18/2024
Certification Date: 07/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1735 IRWINTON RD STE 3A
MILLEDGEVILLE GA
31061-3830
US

IV. Provider business mailing address

50 HURT PLZ SE STE 3A
ATLANTA GA
30303-2946
US

V. Phone/Fax

Practice location:
  • Phone: 470-788-0348
  • Fax:
Mailing address:
  • Phone: 478-788-0348
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: CALEB FLOURNOY
Title or Position: CEO
Credential:
Phone: 478-345-0523