Provider Demographics
NPI:1821329418
Name:ELIJAH, STAN (MT)
Entity Type:Individual
Prefix:MR
First Name:STAN
Middle Name:
Last Name:ELIJAH
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4565 QUAIL LAKES DR STE A1
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5294
Mailing Address - Country:US
Mailing Address - Phone:209-888-8602
Mailing Address - Fax:209-888-8603
Practice Address - Street 1:4565 QUAIL LAKES DR STE A1
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5294
Practice Address - Country:US
Practice Address - Phone:209-888-8602
Practice Address - Fax:209-888-8603
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-20
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA201438173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173C00000XOther Service ProvidersReflexologist