Healthcare Provider Details

I. General information

NPI: 1790778736
Provider Name (Legal Business Name): R T STANLEY HEALTH CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 08/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 RT STANLEY SR PL
LYONS GA
30436-5623
US

IV. Provider business mailing address

PO BOX 407
VIDALIA GA
30475-0407
US

V. Phone/Fax

Practice location:
  • Phone: 912-526-9355
  • Fax: 912-526-8622
Mailing address:
  • Phone: 912-537-4986
  • Fax: 912-526-8622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number138-476
License Number StateGA

VIII. Authorized Official

Name: TONY M OSTEEN
Title or Position: CFO
Credential:
Phone: 912-535-8691