Provider Demographics
NPI:1700278280
Name:EDISON STANFORD
Entity Type:Organization
Organization Name:EDISON STANFORD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEARING INSTRUMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:A
Authorized Official - Last Name:LLOYD
Authorized Official - Suffix:
Authorized Official - Credentials:BC-HIS, ACA
Authorized Official - Phone:801-485-5595
Mailing Address - Street 1:1817 S MAIN ST
Mailing Address - Street 2:7
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-2036
Mailing Address - Country:US
Mailing Address - Phone:801-485-5595
Mailing Address - Fax:
Practice Address - Street 1:1817 S MAIN ST
Practice Address - Street 2:7
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-2036
Practice Address - Country:US
Practice Address - Phone:801-485-5595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-20
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4988314-4601332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies