Healthcare Provider Details

I. General information

NPI: 1710978234
Provider Name (Legal Business Name): EAGLE'S NEST TRUCK STATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 S ROGERS ST
POOLER GA
31322-3116
US

IV. Provider business mailing address

PO BOX 929
POOLER GA
31322-0929
US

V. Phone/Fax

Practice location:
  • Phone: 912-748-6842
  • Fax: 912-748-5214
Mailing address:
  • Phone: 912-748-6842
  • Fax: 912-748-5214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. THOMAS W PENLEY SR.
Title or Position: CEO
Credential:
Phone: 706-855-1773