Healthcare Provider Details

I. General information

NPI: 1720014822
Provider Name (Legal Business Name): KEVIN A STAFFORD MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 07/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 WALNUT ST SUITE B
MONTGOMERY NY
12549-2260
US

IV. Provider business mailing address

20 WALNUT ST SUITE B
MONTGOMERY NY
12549-2260
US

V. Phone/Fax

Practice location:
  • Phone: 845-457-5555
  • Fax: 845-457-5556
Mailing address:
  • Phone: 845-457-5555
  • Fax: 845-457-5556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number024604
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: