Healthcare Provider Details

I. General information

NPI: 1528553716
Provider Name (Legal Business Name): STANFORD JAMES MADDOX
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2018
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 OAK RD UNIT 815
SNELLVILLE GA
30078-1905
US

IV. Provider business mailing address

2250 OAK RD UNIT 815
SNELLVILLE GA
30078-1905
US

V. Phone/Fax

Practice location:
  • Phone: 770-899-6364
  • Fax:
Mailing address:
  • Phone: 770-899-6364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: