Healthcare Provider Details

I. General information

NPI: 1902879273
Provider Name (Legal Business Name): JEREMY LEE FORD ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 N MAIN ST
AKRON OH
44310-3110
US

IV. Provider business mailing address

243 PORTAGE LAKES DR APT A
AKRON OH
44319-2392
US

V. Phone/Fax

Practice location:
  • Phone: 330-379-9488
  • Fax: 330-379-5511
Mailing address:
  • Phone: 330-644-4575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number00-1920
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: