Provider Demographics
NPI:1518355213
Name:SPENCER, STANFORD (OTR)
Entity Type:Individual
Prefix:
First Name:STANFORD
Middle Name:
Last Name:SPENCER
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10040 HILLVIEW DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-5499
Mailing Address - Country:US
Mailing Address - Phone:850-474-7057
Mailing Address - Fax:
Practice Address - Street 1:10040 HILLVIEW DR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-5499
Practice Address - Country:US
Practice Address - Phone:850-474-7057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-03
Last Update Date:2015-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11029314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility