NPIMap

Organization Active NPI

East Georgia Healthcare Center Inc

  • Federally Qualified Health Center (FQHC)
  • Millen, GA
National Provider Identifier
1194258327
Registry record updated Apr 5, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
EAST GEORGIA HEALTHCARE CENTER INC
Practice address
1075 E Winthrope Ave
Millen, GA 30442-6766
Phone
(478) 237-2638
Fax
(478) 237-9138
NPI assigned
Apr 5, 2017
Last updated
Apr 5, 2017By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 5, 2017

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

Authorized official

Name
Jennie Wren C Denmark
Title
Ceo
Phone
(478) 237-6262

Specialties & licenses 1

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

Addresses

Primary practice location

1075 E Winthrope Ave
Millen, GA 30442-6766

Mailing address

215 N Coleman St
Swainsboro, GA 30401-3530
Phone (478) 299-6992

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050722000569 GA Part B Supplier - Clinic/Group Practice 0547228686 Receives reassigned benefits from 49 practitioners
15 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Wadley, GA; Vidalia, GA; Sylvania, GA; Swainsboro, GA; Mount Vernon, GA; Stillmore, GA; Statesboro, GA; Soperton, GA…
O20170609001721 GA Part A Provider - Federally Qualified Health Center (FQHC) 0547228686 Practice locations: Millen, GA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1194258327. Details of each certification follow.

Federally qualified health center certification: CCN 111063

Legal name
EAST GEORGIA HEALTHCARE CENTER, INC.
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 9, 2017
Last certification
Jun 9, 2017
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Oct 19, 1992 in GA
Enrollment address
1075 E Winthrope Ave
Millen, GA 30442-6766

Other NPIs with the same Medicare PAC ID 16

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

View all 16

Other NPIs on the same Medicare enrollment 15

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

View all 15

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
11D2129960East Georgia Healthcare Center, Inc1075 E Winthrope Avenue, Millen, GA 30442Provider-performed microscopyApr 27, 2027

National Provider Directory

National Provider Directory

Locations

433 Barney Ave
Millen, GA 30442
Phone (478) 494-9926

Ownership & related parties

All disclosed owners & managing parties 12

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

NameRoleSinceShare
Joel Salgado Individual Corporate Director Jan 1, 2021 10%
East Georgia Healthcare Center, Inc. Organization, Swainsboro, GA Non-profit Operational/Managerial Control May 1, 2017
Gwendolyn Love Individual Corporate Director May 1, 2017
Lynda Morgan Individual Corporate Director May 1, 2017
Theron D Faison Individual Corporate Director May 1, 2017
Jennie W Denmark Individual W-2 Managing EmployeeChief Executive Officer Jan 1, 2020 10%
Elizabeth Hendrix Individual Corporate Director May 1, 2017
Cleveland White Individual Corporate Director May 1, 2017
Ken Mercer Individual Corporate Officer Mar 1, 2021 10%
Luis Machado Individual Corporate Officer May 1, 2017
Amanda R Brown Individual Corporate Director May 1, 2017
Jill R Sorrells Individual W-2 Managing EmployeeChief Financial Officer Jan 1, 2020 10%

Owners & managing parties with NPI records 16

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

View all 16

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Statesboro Pediatrics and Family Healthcare CenterStatesboro, GA, CCN 111931 Federally qualified health center Other Mar 12, 2013
East Georgia Healthcare Center, Inc.Baxley, GA, CCN 111977 Federally qualified health center Operational/Managerial Control (100%) Jan 1, 2014

Owned or controlled facilities with NPI records 3

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 1

Facilities that share an organizational owner with 5% or greater ownership or operational control.

NPI Registry JSON

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

{
    "created_epoch": "1491350400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1491350400000",
    "number": "1194258327",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "215 N COLEMAN ST",
            "city": "SWAINSBORO",
            "state": "GA",
            "postal_code": "304013530",
            "telephone_number": "478-299-6992",
            "fax_number": "478-237-9138"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1075 E WINTHROPE AVE",
            "city": "MILLEN",
            "state": "GA",
            "postal_code": "304426766",
            "telephone_number": "478-237-2638",
            "fax_number": "478-237-9138"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAST GEORGIA HEALTHCARE CENTER INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-04-05",
        "last_updated": "2017-04-05",
        "status": "A",
        "authorized_official_last_name": "DENMARK",
        "authorized_official_first_name": "JENNIE WREN",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "478-237-6262"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Millen, GA

Sources for this page

Verify at the official NPI Registry.