Healthcare Provider Details

I. General information

NPI: 1386114825
Provider Name (Legal Business Name): CHAD FORD RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2018
Last Update Date: 11/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3535 SOUTHERN BLVD
KETTERING OH
45429-1298
US

IV. Provider business mailing address

9107 MARQUIS DR
MIAMISBURG OH
45342-7421
US

V. Phone/Fax

Practice location:
  • Phone: 937-298-4331
  • Fax:
Mailing address:
  • Phone: 937-219-1208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number369266
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: