NPIMap

Organization Active NPI

South Central Primary Care Center, Inc

  • Federally Qualified Health Center (FQHC)
  • Ocilla, GA
National Provider Identifier
1356709646
Registry record updated Nov 20, 2024
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
Practice address
607C N Irwin Ave
Ocilla, GA 31774-5009
Phone
(229) 468-5020
Fax
(229) 468-5024
NPI assigned
Feb 2, 2016
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 20, 2024

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

607C N Irwin Ave
Ocilla, GA 31774-5009

Mailing address

PO Box 749
Ocilla, GA 31774-0749
Phone (229) 468-9166

Other names 1

  • SOUTH CENTRAL FAMILY HEALTH CARE Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20190828002078 GA Part A Provider - Federally Qualified Health Center (FQHC) 1951395920 Practice locations: Ocilla, GA

Federally qualified health center certification: CCN 111115

Legal name
SOUTH CENTRAL PRIMARY CARE CENTER, INC
Doing business as
SOUTH CENTRAL FAMILY HEALTH CARE
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Aug 28, 2019
Last certification
Aug 28, 2019
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Jun 19, 1992 in GA
Enrollment address
607C N Irwin Ave
Ocilla, GA 31774-5009

Other NPIs with the same Medicare PAC ID 6

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

National Provider Directory

National Provider Directory
Tax ID family
South CTRL Primary Care13 organizations share this tax ID, including this one

Other organizations with this tax ID 12

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

Locations

303 Shirley Ave
Ste B
Douglas, GA 31533
Phone (912) 384-2252

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, 2014
Cindy Giddens Individual Corporate OfficerBoard Member Jan 1, 2013
James Curtis Individual Corporate OfficerBoard Member Jan 1, 2004
Leigh Hendley Individual Corporate OfficerBoard Member Apr 20, 2021
James Alfred Johnson Individual Corporate OfficerBoard Member Apr 20, 2021
Darlene Paulk Individual Corporate OfficerBoard Member May 18, 2021
Robert B Tucker Individual Corporate DirectorCeo Nov 14, 2006
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 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

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

{
    "created_epoch": "1454371200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1732060800000",
    "number": "1356709646",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 749",
            "city": "OCILLA",
            "state": "GA",
            "postal_code": "317740749",
            "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": "607C N IRWIN AVE",
            "city": "OCILLA",
            "state": "GA",
            "postal_code": "317745009",
            "telephone_number": "229-468-5020",
            "fax_number": "229-468-5024"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTH CENTRAL PRIMARY CARE CENTER, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-02-02",
        "last_updated": "2024-11-20",
        "certification_date": "2024-11-20",
        "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": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "SOUTH CENTRAL FAMILY HEALTH CARE",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Ocilla, GA

Sources for this page

Verify at the official NPI Registry.