MEDICARE: ANGELA FORD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker	2048442	TX

General Provider Information

NPI Number	:	1063825834
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA FORD

Provider Business Mailing Address
First Line	:	311 PINEHURST DR
Second Line	:
City	:	SOUR LAKE
State	:	TX
Zip	:	77659-9250
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	311 PINEHURST DR
Second Line	:
City	:	SOUR LAKE
State	:	TX
Zip	:	77659-9250
Country	:	US
Telephone Number	:	903-245-6892
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2014
Last Update Date	:	06/09/2014

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Directions to “ ANGELA FORD ” Practice Location

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