1821079963 NPI number — STANLY MEDICAL SERVICES

Table of content: (NPI 1821079963)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821079963 NPI number — STANLY MEDICAL SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STANLY MEDICAL SERVICES
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:
Provider Other Organization Name Type Code:
6
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:
1821079963
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
320 YADKIN ST
Provider Second Line Business Mailing Address:
STE B
Provider Business Mailing Address City Name:
ALBEMARLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28001-3447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-982-0639
Provider Business Mailing Address Fax Number:
704-983-6153

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 STANLY PKWY
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
LOCUST
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28097-7704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-888-8445
Provider Business Practice Location Address Fax Number:
704-888-8456
Provider Enumeration Date:
11/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
FORTH
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
SCOTT
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
704-983-8756

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 89015PK , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com