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NPI Code Detail

MEDICARE: SAM R FORD CDCA 11

MEDICARE: SAM R FORD CDCA 11
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
1101YA0400XAddiction (Substance Use Disorder) CounselorCDCA162201OH

General Provider Information

NPI Number : 1710674486
Entity Type Code : Individual
Provider Name (Legal Business Name) : SAM R FORD CDCA 11
Provider Business Mailing Address
First Line : 2428 W CENTRAL AVE APT 2B
Second Line :
City : TOLEDO
State : OH
Zip : 43606-3715
Country : US
Telephone Number : 419-360-8251
Fax Number :
Provider Business Practice Location Address
First Line : 500 MADISON AVE STE 340
Second Line :
City : TOLEDO
State : OH
Zip : 43604-1277
Country : US
Telephone Number : 419-360-8251
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/21/2023
Last Update Date : 04/21/2023

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