MEDICARE: MICAH FORDSON

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	225700000X	Massage Therapist	9888	SC

General Provider Information

NPI Number	:	1144756222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICAH FORDSON

Provider Business Mailing Address
First Line	:	3713 COVENANT RD
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29204-4217
Country	:	US
Telephone Number	:	888-753-0009
Fax Number	:

Provider Business Practice Location Address
First Line	:	3739 OAKLEAF RD APT A
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29206-5202
Country	:	US
Telephone Number	:	803-638-2786
Fax Number	:

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

Provider Enumeration Date	:	05/10/2017
Last Update Date	:	05/10/2017

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Directions to “ MICAH FORDSON ” Practice Location

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