=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598173965
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VICKIE LYNN FORD LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2014
-----------------------------------------------------
Last Update Date | 07/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 2ND AVENUE N.E. SUITE 328
-----------------------------------------------------
City | ST. PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-520-5850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2002 YALE AVE
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34207-5256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-520-5850
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MA17279
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------