Healthcare Provider Details

I. General information

NPI: 1962693895
Provider Name (Legal Business Name): ROBERT FORD CRNA PROFESSIONAL NURSING CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2007
Last Update Date: 08/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1141 ROSE AVE
SELMA CA
93662-3241
US

IV. Provider business mailing address

1995 BERGREN CT
KINGSBURG CA
93631-2705
US

V. Phone/Fax

Practice location:
  • Phone: 559-891-2250
  • Fax:
Mailing address:
  • Phone: 559-897-2505
  • Fax: 909-985-3858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberNA1271
License Number StateCA

VIII. Authorized Official

Name: ROBERT H FORD
Title or Position: INCORPORATOR
Credential: CRNA
Phone: 559-897-2505