Healthcare Provider Details

I. General information

NPI: 1336271329
Provider Name (Legal Business Name): MR. STACEY RAYFORD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11628 S CHOCTAW DR
BATON ROUGE LA
70815-2107
US

IV. Provider business mailing address

11628 S CHOCTAW DR
BATON ROUGE LA
70815-2107
US

V. Phone/Fax

Practice location:
  • Phone: 225-275-5999
  • Fax: 225-275-6611
Mailing address:
  • Phone: 225-275-5999
  • Fax: 225-275-6611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number1584827
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number1584894
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number1456462
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: