Healthcare Provider Details

I. General information

NPI: 1447762604
Provider Name (Legal Business Name): MCKENNA FORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2017
Last Update Date: 10/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15820 ADDISON RD
ADDISON TX
75001-3549
US

IV. Provider business mailing address

418 WHITAKER ST
BULLARD TX
75757-0127
US

V. Phone/Fax

Practice location:
  • Phone: 866-919-3240
  • Fax:
Mailing address:
  • Phone: 409-429-4692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number112546
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: