=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962562686
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN THOMAS STACK PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 W CLAIREMONT AVE
-----------------------------------------------------
City | EAU CLAIRE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54701-6103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-839-4359
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 716 W GRAND AVE APT 312
-----------------------------------------------------
City | EAU CLAIRE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54703-5433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-852-0163
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 3557-024
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------