Full Name | |
---|---|
Speciality | Clinic/Center |
Location | 640 Main St N, Pearson, Georgia |
Authorized Official Name and Position | Robert B Tucker (CFO) |
Authorized Official Contact | 2294689166 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
---|---|
204 E 4th St Ocilla GA 31774-1539 Ph: (229) 468-9166 | 640 Main St N Pearson GA 31642 Ph: (912) 544-4569 |
NPI Number | 1558445742 |
---|---|
Provider Enumeration Date | 10/24/2006 |
Last Update Date | 11/26/2024 |
Medicare PECOS PAC ID | 1951395920 |
---|---|
Medicare Enrollment ID | O20061107000444 |
Identifier | Type | State | Issuer |
---|---|---|---|
1558445742 | NPI | - | NPPES |
000611663F | Medicaid | GA |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (Georgia) | Primary |