Provider Demographics
NPI:1245296367
Name:STANFORD AND ASSOCIATES PHYSICAL THERAPY, INC.
Entity type:Organization
Organization Name:STANFORD AND ASSOCIATES PHYSICAL THERAPY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:S
Authorized Official - Last Name:STANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:PT, OCS
Authorized Official - Phone:909-866-6202
Mailing Address - Street 1:PO BOX 1928
Mailing Address - Street 2:
Mailing Address - City:BLUE JAY
Mailing Address - State:CA
Mailing Address - Zip Code:92317-1928
Mailing Address - Country:US
Mailing Address - Phone:909-866-6202
Mailing Address - Fax:909-866-6203
Practice Address - Street 1:42007 FOX FARM RD.
Practice Address - Street 2:SUITE #2
Practice Address - City:BIG BEAR LAKE
Practice Address - State:CA
Practice Address - Zip Code:92315
Practice Address - Country:US
Practice Address - Phone:909-866-6202
Practice Address - Fax:909-866-6203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT193012251X0800X, 2251E1200X
CAPT269412251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
Not Answered2251E1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistErgonomicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ29920ZMedicare ID - Type UnspecifiedORGANIZATION PROVIDER #