Individual
STACEY LARON WATERS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
804 CHILDERS LOOP, BRANDON, FL 33511-6105
(313) 587-2708
Mailing address
804 CHILDERS LOOP, BRANDON, FL 33511-6105
(313) 587-2708
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
—
FL
Other
Enumeration date
06/10/2020
Last updated
06/10/2020
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