Healthcare Provider Details

I. General information

NPI: 1659404952
Provider Name (Legal Business Name): WILLIAM FORD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 S MAIN ST SUITE C
LONGMONT CO
80501-1716
US

IV. Provider business mailing address

205 S MAIN ST SUITE C
LONGMONT CO
80501-1716
US

V. Phone/Fax

Practice location:
  • Phone: 303-702-1612
  • Fax: 303-774-7899
Mailing address:
  • Phone: 303-702-1612
  • Fax: 303-774-7899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0106X
TaxonomyOccupational Health Nurse Practitioner
License Number66841
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: