NPIMap

Organization Active NPI

Four Corners Primary Care Centers, Inc.

  • Federally Qualified Health Center (FQHC)
  • Lawrenceville, GA
National Provider Identifier
1356682959
Registry record updated Sep 27, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
FOUR CORNERS PRIMARY CARE CENTERS, INC.
Practice address
175 Gwinnett Dr
Suite 213
Lawrenceville, GA 30046-8444
Phone
(770) 279-3142
Fax
(770) 234-5210
NPI assigned
Mar 6, 2013
Last updated
Sep 27, 2013By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 27, 2013

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

Authorized official

Name
Ms. Susan A Johnson
Title
Cfo
Phone
(770) 279-3142

Specialties & licenses 1

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

Addresses

Primary practice location

175 Gwinnett Dr
Suite 213
Lawrenceville, GA 30046-8444

Mailing address

5030 Georgia Belle CT
Suite 2066
Norcross, GA 30093-2667
Phone (770) 279-3142

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20150122001012 GA Part A Provider - Federally Qualified Health Center (FQHC) 1951497494 Practice locations: Lawrenceville, GA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1356682959. Details of each certification follow.

Federally qualified health center certification: CCN 111989

Legal name
FOUR CORNERS PRIMARY CARE CENTERS, INC.
Doing business as
FOUR CORNERS PRIMARY CARE CENTERS AT VPH
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jan 22, 2015
Last certification
Jan 22, 2015
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Sep 28, 2006 in GA
Enrollment address
175 Gwinnett Drive
Suite 213
Lawrenceville, GA 30046-8457

Other NPIs with the same Medicare PAC ID 3

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

National Provider Directory

National Provider Directory
Tax ID family
Four Corners Prim Care4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

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

Locations

113 Towne Center Pkwy
Hoschton, GA 30548

175 Gwinnett Dr
Ste 213
Lawrenceville, GA 30046
Phone (678) 377-3745

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
Angel G Amaro Individual Corporate DirectorBoard Member Nov 14, 2014
William G Mayfield Individual Corporate DirectorBoard Member Jan 20, 2009
Walter Murray Individual Corporate OfficerCfo Nov 14, 2014
Corporate DirectorCfo Nov 14, 2014
Vanessa M Robinson-Dooley Individual Corporate DirectorBoard Member Feb 15, 2011
Brian O Williams Individual W-2 Managing EmployeeCeo Nov 14, 2014
Rossana Mangual Individual Corporate DirectorBoard Member Feb 1, 2014
Mary Jane Labonte Individual Corporate DirectorBoard Member Sep 16, 2008
Angela F Watkins Individual Corporate DirectorBoard Member Jan 24, 2014
Jeanine B Oliga Individual Corporate DirectorMedical Director Mar 24, 2014
Julie a Crosby- San Miguel Individual Corporate DirectorBoard Member May 8, 2010
Lily Arfa Morehouse Individual Corporate DirectorBoard Member Mar 18, 2014

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 13

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 13

NPI Registry JSON

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

{
    "created_epoch": "1362528000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1380240000000",
    "number": "1356682959",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5030 GEORGIA BELLE CT",
            "address_2": "SUITE 2066",
            "city": "NORCROSS",
            "state": "GA",
            "postal_code": "300932667",
            "telephone_number": "770-279-3142",
            "fax_number": "770-234-5210"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "175 GWINNETT DR",
            "address_2": "SUITE 213",
            "city": "LAWRENCEVILLE",
            "state": "GA",
            "postal_code": "300468444",
            "telephone_number": "770-279-3142",
            "fax_number": "770-234-5210"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FOUR CORNERS PRIMARY CARE CENTERS, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-03-06",
        "last_updated": "2013-09-27",
        "status": "A",
        "authorized_official_last_name": "JOHNSON",
        "authorized_official_first_name": "SUSAN",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "770-279-3142",
        "authorized_official_name_prefix": "Ms."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Lawrenceville, GA

Sources for this page

Verify at the official NPI Registry.