Healthcare Provider Details

I. General information

NPI: 1245296367
Provider Name (Legal Business Name): STANFORD AND ASSOCIATES PHYSICAL THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42007 FOX FARM RD. SUITE #2
BIG BEAR LAKE CA
92315
US

IV. Provider business mailing address

PO BOX 1928
BLUE JAY CA
92317-1928
US

V. Phone/Fax

Practice location:
  • Phone: 909-866-6202
  • Fax: 909-866-6203
Mailing address:
  • Phone: 909-866-6202
  • Fax: 909-866-6203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251E1200X
TaxonomyErgonomics Physical Therapist
License NumberPT19301
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT19301
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT26941
License Number StateCA

VIII. Authorized Official

Name: MARY S STANFORD
Title or Position: PRESIDENT
Credential: P.T., O.C.S.
Phone: 909-866-6202