Provider Demographics
NPI:1225455074
Name:STACKHOUSE, ROOSEVELT JR (RN)
Entity Type:Individual
Prefix:
First Name:ROOSEVELT
Middle Name:
Last Name:STACKHOUSE
Suffix:JR
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 648
Mailing Address - Street 2:521 GILCHRIST ROAD
Mailing Address - City:MULLINS
Mailing Address - State:SC
Mailing Address - Zip Code:29574-0648
Mailing Address - Country:US
Mailing Address - Phone:843-464-0767
Mailing Address - Fax:843-464-0767
Practice Address - Street 1:1705 W EVANS ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-3331
Practice Address - Country:US
Practice Address - Phone:843-774-1577
Practice Address - Fax:843-774-1047
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-18
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37318163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health