Provider Demographics
NPI:1124103536
Name:RUFUS B. ANTLEY, OD
Entity type:Organization
Organization Name:RUFUS B. ANTLEY, OD
Other - Org Name:<UNAVAIL>
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:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:WAGENER
Mailing Address - State:SC
Mailing Address - Zip Code:29164
Mailing Address - Country:US
Mailing Address - Phone:803-564-6728
Mailing Address - Fax:803-564-6750
Practice Address - Street 1:149 N. MAIN ST
Practice Address - Street 2:
Practice Address - City:WAGENER
Practice Address - State:SC
Practice Address - Zip Code:29164
Practice Address - Country:US
Practice Address - Phone:803-564-6728
Practice Address - Fax:803-564-6750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2008-04-20
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
SCDA9844Medicaid
SC=========OtherTRICARE
SC=========OtherTRICARE
SCT241160282Medicare PIN