Healthcare Provider Details

I. General information

NPI: 1568844991
Provider Name (Legal Business Name): SOUTH CENTRAL PRIMARY CARE CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2015
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N BARTOW ST
NASHVILLE GA
31639-1435
US

IV. Provider business mailing address

204 E 4TH ST
OCILLA GA
31774-1539
US

V. Phone/Fax

Practice location:
  • Phone: 229-686-2774
  • Fax: 229-543-1348
Mailing address:
  • Phone: 229-468-9166
  • Fax: 229-468-9188

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: MR. ROBERT B TUCKER JR.
Title or Position: CEO
Credential: CEO
Phone: 229-468-9166