=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285325282
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOUR CORNERS PRIMARY CARE CENTERS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2023
-----------------------------------------------------
Last Update Date | 05/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 318 W PIKE ST STE 100
-----------------------------------------------------
City | LAWRENCEVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30046-3234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-806-2928
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5300 OAKBROOK PKWY STE 130
-----------------------------------------------------
City | NORCROSS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30093-2261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-279-3176
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | BRIAN ONEAL WILLIAMS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 770-279-3141
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------