1003977497 NPI number — MRS. STACEY RENEE SANDERS MS OTRL

Table of content: MRS. STACEY RENEE SANDERS MS OTRL (NPI 1003977497)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003977497 NPI number — MRS. STACEY RENEE SANDERS MS OTRL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SANDERS
Provider First Name:
STACEY
Provider Middle Name:
RENEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS OTRL
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COWART
Provider Other First Name:
STACEY
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1003977497
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/16/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2421 GA HIGHWAY 313
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SYLVESTER
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31791-7434
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-777-9539
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 PALMYRA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31701-1528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-434-2580
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  OT004223 , 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)





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