Provider Demographics
NPI:1407555048
Name:STAFFORD, MYLES
Entity Type:Individual
Prefix:
First Name:MYLES
Middle Name:
Last Name:STAFFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 BROOKSTONE DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-5008
Mailing Address - Country:US
Mailing Address - Phone:573-379-6403
Mailing Address - Fax:
Practice Address - Street 1:151 SOUTHWEST DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-5828
Practice Address - Country:US
Practice Address - Phone:870-930-9336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-02
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist