=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447029384
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RST ADVANCEMENT FLORIDA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2023
-----------------------------------------------------
Last Update Date | 01/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1015 ARTHUR J MOORE DR
-----------------------------------------------------
City | ST SIMONS ISLAND
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31522-2206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-719-7404
-----------------------------------------------------
Fax | 904-719-7405
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1015 ARTHUR J MOORE DR
-----------------------------------------------------
City | ST SIMONS ISLAND
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31522-2206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-719-7404
-----------------------------------------------------
Fax | 904-719-7405
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN ASSISTANT
-----------------------------------------------------
Name | MR. JONATHAN SEAN STEPHENS
-----------------------------------------------------
Credential | PA-C
-----------------------------------------------------
Telephone | 912-270-5676
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------