Provider Demographics
NPI:1790778736
Name:R T STANLEY HEALTH CENTER LLC
Entity Type:Organization
Organization Name:R T STANLEY HEALTH CENTER LLC
Other - Org Name:R T STANLEY HEALTH CENTER LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:M
Authorized Official - Last Name:OSTEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-535-8691
Mailing Address - Street 1:PO BOX 407
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-0407
Mailing Address - Country:US
Mailing Address - Phone:912-537-4986
Mailing Address - Fax:912-526-8622
Practice Address - Street 1:110 RT STANLEY SR PL
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:GA
Practice Address - Zip Code:30436-5623
Practice Address - Country:US
Practice Address - Phone:912-526-9355
Practice Address - Fax:912-526-8622
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEAST REGIONAL PRIMARY CARE CORP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-24
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA138-476261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11-8904OtherMEDICARE ID-TYPE UNSPECIFIED
GA0003111970AMedicaid
GA202G708591Medicare PIN