1790778736 NPI number — R T STANLEY HEALTH CENTER LLC

Table of content: (NPI 1790778736)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790778736 NPI number — R T STANLEY HEALTH CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
R T STANLEY HEALTH CENTER LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
R T STANLEY HEALTH CENTER LLC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790778736
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 407
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIDALIA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30475-0407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-537-4986
Provider Business Mailing Address Fax Number:
912-526-8622

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 RT STANLEY SR PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LYONS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30436-5623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-526-9355
Provider Business Practice Location Address Fax Number:
912-526-8622
Provider Enumeration Date:
08/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
OSTEEN
Authorized Official First Name:
TONY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
912-535-8691

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , with the licence number:  138-476 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 11-8904 . This is a "MEDICARE ID-TYPE UNSPECIFIED" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 0003111970A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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