Healthcare Provider Details

I. General information

NPI: 1649830209
Provider Name (Legal Business Name): AUTUMN LASHAE FORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 06/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9441 COMMON ST STE B
BATON ROUGE LA
70809-1463
US

IV. Provider business mailing address

9441 COMMON ST STE B
BATON ROUGE LA
70809-1463
US

V. Phone/Fax

Practice location:
  • Phone: 225-923-3733
  • Fax: 225-923-3735
Mailing address:
  • Phone: 225-923-3733
  • Fax: 225-923-3735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: