Healthcare Provider Details

I. General information

NPI: 1700458312
Provider Name (Legal Business Name): TRADERRIC FORD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2021
Last Update Date: 07/13/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2104 GREENBRIAR DR
SOUTHLAKE TX
76092-8355
US

IV. Provider business mailing address

4712 MIRAGE CT APT 1423
EULESS TX
76040-8905
US

V. Phone/Fax

Practice location:
  • Phone: 817-442-9022
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-18-15039
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: