Healthcare Provider Details

I. General information

NPI: 1790974293
Provider Name (Legal Business Name): 26KC CENTER FOR FAMILY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2007
Last Update Date: 10/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 TOWNE PARK DR SUIT 400,
RINCON GA
31326-5156
US

IV. Provider business mailing address

800 TOWNE PARK DR SUIT 400, P.O .BOX 1599
RINCON GA
31326-5156
US

V. Phone/Fax

Practice location:
  • Phone: 912-826-3373
  • Fax:
Mailing address:
  • Phone: 912-308-8799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number50331
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number50331
License Number StateGA

VIII. Authorized Official

Name: DR. KENNEDY KELECHI OKERE
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 912-826-3373