Provider Demographics
NPI:1619905478
Name:CRADDOCK, STANLEY WAYNE (LAT)
Entity Type:Individual
Prefix:MR
First Name:STANLEY
Middle Name:WAYNE
Last Name:CRADDOCK
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3208 RAVEN GLEN CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-1509
Mailing Address - Country:US
Mailing Address - Phone:704-576-7785
Mailing Address - Fax:704-366-5678
Practice Address - Street 1:7301 SARDIS RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28270-6063
Practice Address - Country:US
Practice Address - Phone:704-363-7147
Practice Address - Fax:704-366-5678
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00862255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer