{
"Npi": {
"NPI": "1568844991",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "SOUTH CENTRAL PRIMARY CARE CENTER, INC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "204 E 4TH ST",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "OCILLA",
"MailingAddressStateName": "GA",
"MailingAddressPostalCode": "31774-1539",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "229-468-9166",
"MailingAddressFaxNumber": "229-468-9188",
"FirstLinePracticeLocationAddress": "201 N BARTOW ST",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "NASHVILLE",
"PracticeLocationAddressStateName": "GA",
"PracticeLocationAddressPostalCode": "31639-1435",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "229-686-2774",
"PracticeLocationAddressFaxNumber": "229-543-1348",
"EnumerationDate": "06/22/2015",
"LastUpdateDate": "11/26/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "TUCKER",
"AuthorizedOfficialFirstName": "ROBERT",
"AuthorizedOfficialMiddleName": "B",
"AuthorizedOfficialTitle": "CEO",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": "JR.",
"AuthorizedOfficialCredential": "CEO",
"AuthorizedOfficialTelephoneNumber": "229-468-9166",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QF0400X",
"TaxonomyName": "Federally Qualified Health Center (FQHC)",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}