MEDICARE: MR. STANFORD B GIVENS JR. 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	PT 24956	FL

General Provider Information

NPI Number	:	1841675832
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. STANFORD B GIVENS JR. DPT

Provider Business Mailing Address
First Line	:	2505 FAIRWAY DR
Second Line	:
City	:	PALATKA
State	:	FL
Zip	:	32177-9785
Country	:	US
Telephone Number	:	904-669-8427
Fax Number	:

Provider Business Practice Location Address
First Line	:	3601 38TH AVE S
Second Line	:	COMPANY C, 53RD BSB
City	:	ST PETERSBURG
State	:	FL
Zip	:	33711-4329
Country	:	US
Telephone Number	:	727-893-2737
Fax Number	:

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

Provider Enumeration Date	:	07/20/2015
Last Update Date	:	07/20/2015

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