MEDICARE: KACI LYNN STAFFORD DPT

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	1234612	TX

General Provider Information

NPI Number	:	1730512930
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KACI LYNN STAFFORD DPT

Provider Business Mailing Address
First Line	:	335 ROSELANE ST NW
Second Line	:	SUITE 201
City	:	MARIETTA
State	:	GA
Zip	:	30060-7902
Country	:	US
Telephone Number	:	470-259-5226
Fax Number	:	267-321-2044

Provider Business Practice Location Address
First Line	:	2960 ELDORADO PKWY
Second Line	:	SUITE 75
City	:	MCKINNEY
State	:	TX
Zip	:	75070-4373
Country	:	US
Telephone Number	:	972-562-0713
Fax Number	:	972-562-0932

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

Provider Enumeration Date	:	08/12/2013
Last Update Date	:	03/01/2016

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