Healthcare Provider Details

I. General information

NPI: 1790940450
Provider Name (Legal Business Name): MICHELLE MARIE FORD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 08/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13111 PARK ST
RUSSELLVILLE MO
65074-1232
US

IV. Provider business mailing address

13111 PARK ST
RUSSELLVILLE MO
65074-1232
US

V. Phone/Fax

Practice location:
  • Phone: 573-782-3534
  • Fax: 573-782-3435
Mailing address:
  • Phone: 573-782-3534
  • Fax: 573-782-3435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number104884
License Number StateMO

VIII. Authorized Official

Name: MS. LAURA RYAN
Title or Position: SPECIAL SERVICES DIRECTOR
Credential: MED.
Phone: 573-782-3352