MEDICARE: SOUTH CENTRAL PRIMARY CARE CENTER, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1568844991
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH CENTRAL PRIMARY CARE CENTER, INC

Provider Business Mailing Address
First Line	:	204 E 4TH ST
Second Line	:
City	:	OCILLA
State	:	GA
Zip	:	31774-1539
Country	:	US
Telephone Number	:	229-468-9166
Fax Number	:	229-468-9188

Provider Business Practice Location Address
First Line	:	201 N BARTOW ST
Second Line	:
City	:	NASHVILLE
State	:	GA
Zip	:	31639-1435
Country	:	US
Telephone Number	:	229-686-2774
Fax Number	:	229-543-1348

Authorized Official
Title or Position	:	CEO
Name	:	MR. ROBERT B TUCKER JR.
Credential	:	CEO
Telephone Number	:	229-468-9166

Provider Enumeration Date	:	06/22/2015
Last Update Date	:	11/26/2024

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