Provider Demographics
NPI:1316250350
Name:DORR, STACI (CO)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:DORR
Suffix:
Gender:F
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 24905
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27114-4905
Mailing Address - Country:US
Mailing Address - Phone:336-397-2165
Mailing Address - Fax:336-397-2167
Practice Address - Street 1:208 ASHVILLE AVE
Practice Address - Street 2:SUITE 16
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-6678
Practice Address - Country:US
Practice Address - Phone:919-851-7385
Practice Address - Fax:919-851-7387
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-20
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO003116OtherABC CERTIFIED ORTHOTIST CERTIFICATION