Provider Demographics
NPI:1386829026
Name:RUFUS B ANTLEY
Entity Type:Organization
Organization Name:RUFUS B ANTLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:L
Authorized Official - Last Name:ANTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-532-9870
Mailing Address - Street 1:117 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:BATESBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29006-2108
Mailing Address - Country:US
Mailing Address - Phone:803-532-9870
Mailing Address - Fax:803-532-1259
Practice Address - Street 1:117 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:BATESBURG
Practice Address - State:SC
Practice Address - Zip Code:29006-2108
Practice Address - Country:US
Practice Address - Phone:803-532-9870
Practice Address - Fax:803-532-1259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-31
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC433152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDA9991Medicaid
SC=========-002OtherTRICARE
SC0652760001Medicare NSC
SC=========-002OtherTRICARE