Basic Information
| Provider Information | |||||||||
| NPI: | 1083738355 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STANLEY T. DAY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | FAMILY CARE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 179 | ||||||||
| Address2: | |||||||||
| City: | NIMITZ | ||||||||
| State: | WV | ||||||||
| PostalCode: | 259780179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044662501 | ||||||||
| FaxNumber: | 3044662513 | ||||||||
| Practice Location | |||||||||
| Address1: | 197 PLEASANT ST | ||||||||
| Address2: | |||||||||
| City: | HINTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 259512540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044662501 | ||||||||
| FaxNumber: | 3044662513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 06/20/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DAY | ||||||||
| AuthorizedOfficialFirstName: | STANLEY | ||||||||
| AuthorizedOfficialMiddleName: | TYLER | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3044662501 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 13118 | WV | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 0034320000 | 05 | WV | MEDICAID | 0056758000 | 05 | WV | MEDICAID |