Provider Demographics
NPI:1265296115
Name:MATLOCK, STACEY
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MATLOCK
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:PO BOX 181
Mailing Address - Street 2:
Mailing Address - City:CANDO
Mailing Address - State:ND
Mailing Address - Zip Code:58324-0181
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:306 7TH AVE
Practice Address - Street 2:
Practice Address - City:CANDO
Practice Address - State:ND
Practice Address - Zip Code:58324-6500
Practice Address - Country:US
Practice Address - Phone:701-370-3804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider