Provider Demographics
NPI:1134679558
Name:GARCIA, STACEY ROSE
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:ROSE
Last Name:GARCIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 W 214TH ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90501
Mailing Address - Country:US
Mailing Address - Phone:310-955-0855
Mailing Address - Fax:
Practice Address - Street 1:1445 W 214TH ST
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90501
Practice Address - Country:US
Practice Address - Phone:310-955-0855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-10
Last Update Date:2019-01-30
Deactivation Date:2019-01-15
Deactivation Code:
Reactivation Date:2019-01-30
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program