Healthcare Provider Details

I. General information

NPI: 1457770612
Provider Name (Legal Business Name): PRIMARY HEALTH CARE CENTER OF DADE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2014
Last Update Date: 04/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11638 HIGHWAY 27 SUITE 8
SUMMERVILLE GA
30747-8514
US

IV. Provider business mailing address

13570 N MAIN ST
TRENTON GA
30752-2012
US

V. Phone/Fax

Practice location:
  • Phone: 706-657-7575
  • Fax:
Mailing address:
  • Phone: 706-657-7575
  • Fax:

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 L BUFFINGTON
Title or Position: ADMINISTRATIVE SERVICES MANAGER
Credential:
Phone: 706-657-7575