1376706135 NPI number — TERRANCE L FORD HIS

Table of content: TERRANCE L FORD HIS (NPI 1376706135)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376706135 NPI number — TERRANCE L FORD HIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORD
Provider First Name:
TERRANCE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
HIS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376706135
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
140 CORPORATE DR
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
BEAVER DAM
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53916-1281
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
920-887-9655

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1004 1ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STEVENS POINT
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54481-2652
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-341-4250
Provider Business Practice Location Address Fax Number:
920-887-9655
Provider Enumeration Date:
07/02/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 237700000X , with the licence number:  1294-060 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 42840500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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