Healthcare Provider Details

I. General information

NPI: 1144796145
Provider Name (Legal Business Name): ZACHERY DALE STANDIFORD ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2018
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

468 CASPARI DRIVE
NATCHITOCHES LA
71497-4271
US

IV. Provider business mailing address

2122 BERTHA ST
OPELOUSAS LA
70570-9735
US

V. Phone/Fax

Practice location:
  • Phone: 318-357-4035
  • Fax:
Mailing address:
  • Phone: 337-692-5742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number324095
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: