MEDICARE: MRS. BARBARA JEAN STACY PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT 9115	CA

General Provider Information

NPI Number	:	1215082581
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. BARBARA JEAN STACY PT

Provider Business Mailing Address
First Line	:	31700 RAILROAD CANYON RD STE 1
Second Line	:
City	:	CANYON LAKE
State	:	CA
Zip	:	92587-9453
Country	:	US
Telephone Number	:	951-246-2670
Fax Number	:	951-246-2672

Provider Business Practice Location Address
First Line	:	31700 RAILROAD CANYON RD STE 1
Second Line	:
City	:	CANYON LAKE
State	:	CA
Zip	:	92587-9453
Country	:	US
Telephone Number	:	951-246-2670
Fax Number	:	951-246-2672

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2007
Last Update Date	:	07/08/2007

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