Basic Information
Provider Information | |||||||||
NPI: | 1588017412 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | J C LEWIS PRIMARY HEALTH CARE CENTER INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 125 FAHM ST | ||||||||
Address2: |   | ||||||||
City: | SAVANNAH | ||||||||
State: | GA | ||||||||
PostalCode: | 314012391 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9124958887 | ||||||||
FaxNumber: | 9124958881 | ||||||||
Practice Location | |||||||||
Address1: | 1110 MAY ST | ||||||||
Address2: |   | ||||||||
City: | SAVANNAH | ||||||||
State: | GA | ||||||||
PostalCode: | 314155470 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9124958887 | ||||||||
FaxNumber: | 9124958881 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/15/2016 | ||||||||
LastUpdateDate: | 07/15/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ADAMS | ||||||||
AuthorizedOfficialFirstName: | LAURA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 9124958887 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | J C LEWIS PRIMARY HEALTH CARE CENTER | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 003135130A | 05 | GA |   | MEDICAID | 111978 | 01 | GA | MEDICARE PTAN | OTHER |