Provider Demographics
NPI:1982104832
Name:STANDIFORD, TIMOTHY DYLAN
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DYLAN
Last Name:STANDIFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:TIMOTHY
Other - Middle Name:DYLAN
Other - Last Name:DRENNAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 922
Mailing Address - Street 2:
Mailing Address - City:FRITCH
Mailing Address - State:TX
Mailing Address - Zip Code:79036-0922
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 PUEBLO RD
Practice Address - Street 2:
Practice Address - City:FRITCH
Practice Address - State:TX
Practice Address - Zip Code:79036-5041
Practice Address - Country:US
Practice Address - Phone:760-330-1741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-16
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant