Healthcare Provider Details

I. General information

NPI: 1891276325
Provider Name (Legal Business Name): CLINT DAVID FORD PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2018
Last Update Date: 08/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9101 PANTHERWAY
WOODWAY TX
76712-8614
US

IV. Provider business mailing address

10008 SHAWNEE TRL
WACO TX
76712-8875
US

V. Phone/Fax

Practice location:
  • Phone: 254-537-9200
  • Fax:
Mailing address:
  • Phone: 254-723-4441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number2018131
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2018131
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: