Healthcare Provider Details

I. General information

NPI: 1437102449
Provider Name (Legal Business Name): PRIMARY HEALTH CARE CENTER OF DADE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 01/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13570 N MAIN ST
TRENTON GA
30752-2012
US

IV. Provider business mailing address

13570 N MAIN ST
TRENTON GA
30752-2012
US

V. Phone/Fax

Practice location:
  • Phone: 706-956-2665
  • Fax: 706-657-5885
Mailing address:
  • Phone: 706-657-7575
  • Fax: 706-657-6575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: LINDA S NIXON
Title or Position: CHIEF FINANCIAL OFFICER
Credential: CFO
Phone: 706-657-7575