MEDICARE: RUFUS B. ANTLEY, OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	433	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124103536
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUFUS B. ANTLEY, OD

Provider Business Mailing Address
First Line	:	PO BOX 130
Second Line	:
City	:	WAGENER
State	:	SC
Zip	:	29164
Country	:	US
Telephone Number	:	803-564-6728
Fax Number	:	803-564-6750

Provider Business Practice Location Address
First Line	:	149 N. MAIN ST
Second Line	:
City	:	WAGENER
State	:	SC
Zip	:	29164
Country	:	US
Telephone Number	:	803-564-6728
Fax Number	:	803-564-6750

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. BARBARA L. ANTLEY
Credential	:
Telephone Number	:	803-532-9870

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	04/20/2008

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