Basic Information
| Provider Information | |||||||||
| NPI: | 1922301472 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | J.C. LEWIS PRIMARY HEALTHCARE CENTER, INC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5 MALL ANX | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314064738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9127216705 | ||||||||
| FaxNumber: | 9124958881 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 MALL ANX | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314064738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9127216701 | ||||||||
| FaxNumber: | 9124958881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2010 | ||||||||
| LastUpdateDate: | 05/25/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DOUSE | ||||||||
| AuthorizedOfficialFirstName: | RENA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9127216701 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/25/2021 | ||||||||
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 | 003110256A | 05 | GA | MEDICAID | 003156658A | 05 | GA | MEDICAID | 003104809A | 05 | GA | MEDICAID | 003135130A | 05 | GA | MEDICAID | 003122845A | 05 | GA | MEDICAID | 003122855A | 05 | GA | MEDICAID |