Healthcare Provider Details

I. General information

NPI: 1710965900
Provider Name (Legal Business Name): FORD CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11973 AUGUSTA RD
LAVONIA GA
30553-1283
US

IV. Provider business mailing address

24 HARTWELL ST
ROYSTON GA
30662-4213
US

V. Phone/Fax

Practice location:
  • Phone: 706-356-8181
  • Fax: 706-356-8081
Mailing address:
  • Phone: 706-245-7380
  • Fax: 706-245-6726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NICOLE FORD
Title or Position: OFFICE MANAGER
Credential: NP-C
Phone: 706-245-7380