Healthcare Provider Details

I. General information

NPI: 1194731968
Provider Name (Legal Business Name): DIANE MARIE FORD R.D., C.D.E.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 IRVING AVE
SYRACUSE NY
13210-2716
US

IV. Provider business mailing address

2711 HAYES RD E
BOONVILLE NY
13309-5279
US

V. Phone/Fax

Practice location:
  • Phone: 315-334-7100
  • Fax: 315-334-7171
Mailing address:
  • Phone: 315-942-3316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: