Basic Information
| Provider Information | |||||||||
| NPI: | 1790778736 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | R T STANLEY HEALTH CENTER LLC | ||||||||
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| OtherOrganizationName: | R T STANLEY HEALTH CENTER LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 407 | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304750407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125374986 | ||||||||
| FaxNumber: | 9125268622 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 RT STANLEY SR PL | ||||||||
| Address2: | |||||||||
| City: | LYONS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304365623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125269355 | ||||||||
| FaxNumber: | 9125268622 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2005 | ||||||||
| LastUpdateDate: | 08/27/2019 | ||||||||
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| AuthorizedOfficialLastName: | OSTEEN | ||||||||
| AuthorizedOfficialFirstName: | TONY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9125358691 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHEAST REGIONAL PRIMARY CARE CORP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 138-476 | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 11-8904 | 01 | GA | MEDICARE ID-TYPE UNSPECIFIED | OTHER | 0003111970A | 05 | GA | MEDICAID |