Provider Demographics
NPI:1164460168
Name:STACEY WOOD
Entity Type:Organization
Organization Name:STACEY WOOD
Other - Org Name:GRAND JUNCTION PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:970-242-0111
Mailing Address - Street 1:321 ROOD AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-2451
Mailing Address - Country:US
Mailing Address - Phone:970-242-0111
Mailing Address - Fax:970-263-4334
Practice Address - Street 1:321 ROOD AVE
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-2451
Practice Address - Country:US
Practice Address - Phone:970-242-0111
Practice Address - Fax:970-263-4334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO68526571Medicaid
COC541418Medicare PIN