NPIMap

Organization Active NPI

South Central Primary Care Center, Inc

Doing business as Kids Health

  • Federally Qualified Health Center (FQHC)
  • Douglas, GA
National Provider Identifier
1063840296
Registry record updated Apr 3, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
SOUTH CENTRAL PRIMARY CARE CENTER, INC
Doing business as
Kids Health
South Central Primary Care
Practice address
303 Shirley Ave
Ste B
Douglas, GA 31533
Phone
(912) 384-2474
Fax
(912) 384-4995
NPI assigned
Oct 25, 2013
Last updated
Apr 3, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 3, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Robert B Tucker Jr., CEO
Title
Ceo
Phone
(229) 468-9166

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

303 Shirley Ave
Ste B
Douglas, GA 31533

Mailing address

204 E 4TH St
P O Box 749
Ocilla, GA 31774-1539
Phone (229) 468-9166

Other identifiers 1

IdentifierTypeStateIssuer
003140047AMedicaidGA

Other names 2

  • KIDS HEALTH Doing business as
  • SOUTH CENTRAL PRIMARY CARE Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20070629000611 GA Part A Provider - Federally Qualified Health Center (FQHC) 1951395920 1 other NPI on this enrollment
Practice locations: Douglas, GA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1063840296. Details of each certification follow.

Federally qualified health center certification: CCN 111858

Legal name
SOUTH CENTRAL PRIMARY CARE CENTER, INC
Doing business as
SOUTH CENTRAL PRIMARY CARE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 18, 1998
Last certification
Nov 18, 1998
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Jun 19, 1992 in GA
Enrollment address
303 Shirley Ave
Ste B
Douglas, GA 31533-2373
Related CCNs
111829

Other NPIs with the same Medicare PAC ID 6

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
South Central Primary C14 organizations share this tax ID, including this one

Other organizations with this tax ID 13

Organizations that report the same tax identification number in the National Provider Directory.

View all 13

Locations

15 S Railroad St
Lenox, GA 31637
Phone (229) 546-4206

121 N Cherry St
Ocilla, GA 31774
Phone (229) 468-9160

602 N Irwin Ave
Ste B
Ocilla, GA 31774
Phone (229) 468-7762

609 N Irwin Ave
Ocilla, GA 31774
Phone (229) 468-7762

Ownership & related parties

All disclosed owners & managing parties 11

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Gary H Paulk Individual Corporate OfficerBoard Chairperson Jan 1, 1998
Tracy McClelland Individual Corporate OfficerBoard Member Jan 1, 2009
Shelia Taylor Individual Corporate OfficerBoard Member Jan 1, 2014
Thlando E Paulk Individual Corporate OfficerBoard Member Jan 1, 2010
Cindy Giddens Individual Corporate OfficerBoard Member Jan 1, 2013
James Curtis Individual Corporate OfficerBoard Member Jan 1, 2014
Leigh Hendley Individual Corporate OfficerBoard Member Feb 1, 2022
James Alfred Johnson Individual Corporate OfficerBoard Member Feb 1, 2022
Darlene Paulk Individual Corporate OfficerBoard Member May 1, 2022
Robert B Tucker Individual Corporate DirectorCeo Aug 16, 2004
W-2 Managing EmployeeCeo Aug 16, 2004 100%
Samuel Martinez Individual Corporate OfficerBoard Member May 19, 2015

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 22

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 22

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1382659200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1743638400000",
    "number": "1063840296",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "204 E 4TH ST",
            "address_2": "P O BOX 749",
            "city": "OCILLA",
            "state": "GA",
            "postal_code": "317741539",
            "telephone_number": "229-468-9166",
            "fax_number": "229-468-9188"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "303 SHIRLEY AVE",
            "address_2": "STE B",
            "city": "DOUGLAS",
            "state": "GA",
            "postal_code": "31533",
            "telephone_number": "912-384-2474",
            "fax_number": "912-384-4995"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTH CENTRAL PRIMARY CARE CENTER, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-10-25",
        "last_updated": "2025-04-03",
        "certification_date": "2025-04-03",
        "status": "A",
        "authorized_official_last_name": "TUCKER",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_middle_name": "B",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "229-468-9166",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_name_suffix": "Jr.",
        "authorized_official_credential": "CEO"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "003140047A",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "KIDS HEALTH",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "SOUTH CENTRAL PRIMARY CARE",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Douglas, GA

Sources for this page

Verify at the official NPI Registry.