Healthcare Provider Details

I. General information

NPI: 1225752637
Provider Name (Legal Business Name): TIMOTHY DEAN STAFFORD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2022
Last Update Date: 10/06/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9344 SHOESTRING TRL
WILLIAMSBURG WV
24991-0141
US

IV. Provider business mailing address

PO BOX 141
WILLIAMSBURG WV
24991-0141
US

V. Phone/Fax

Practice location:
  • Phone: 304-661-2336
  • Fax:
Mailing address:
  • Phone: 304-667-6678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License NumberEMP4738
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: