Basic Information
| Provider Information | |||||||||
| NPI: | 1841432044 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SCREVEN COUNTY FAMILY HEALTH CENTER, LLC | ||||||||
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| OtherOrganizationName: | OPTIM PRIMARY CARE - SYLVANIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 EAST DERENNE AVENUE | ||||||||
| Address2: | ATTN: PROVIDER ENROLLMENT | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9126441626 | ||||||||
| FaxNumber: | 9126445260 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 ROCKY FORD RD | ||||||||
| Address2: | |||||||||
| City: | SYLVANIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304672027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125647133 | ||||||||
| FaxNumber: | 9125642617 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2009 | ||||||||
| LastUpdateDate: | 10/21/2015 | ||||||||
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| AuthorizedOfficialLastName: | GUENTHNER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | SECRETARY OF SCREVEN COUNTY HOSPITA | ||||||||
| AuthorizedOfficialTelephone: | 3126278247 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SCREVEN COUNTY FAMILY HEALTH CENTER, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 021262 | GA | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QR1300X | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.