Healthcare Provider Details

I. General information

NPI: 1982104832
Provider Name (Legal Business Name): TIMOTHY DYLAN STANDIFORD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: TIMOTHY DYLAN DRENNAN

II. Dates (important events)

Enumeration Date: 02/16/2018
Last Update Date: 02/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 PUEBLO RD
FRITCH TX
79036-5041
US

IV. Provider business mailing address

PO BOX 922
FRITCH TX
79036-0922
US

V. Phone/Fax

Practice location:
  • Phone: 760-330-1741
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: