Provider Demographics
NPI:1861089302
Name:STAFFORD, ENDRAIN N
Entity type:Individual
Prefix:
First Name:ENDRAIN
Middle Name:N
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8900 FUSCHIA CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-9420
Mailing Address - Country:US
Mailing Address - Phone:704-241-1163
Mailing Address - Fax:
Practice Address - Street 1:6100 TEANECK PL
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-4063
Practice Address - Country:US
Practice Address - Phone:704-241-1163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-30
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home