Provider Demographics
NPI:1548529274
Name:FORD, KIM MARIE
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:MARIE
Last Name:FORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 55
Mailing Address - Street 2:
Mailing Address - City:ODANAH
Mailing Address - State:WI
Mailing Address - Zip Code:54861-0055
Mailing Address - Country:US
Mailing Address - Phone:715-682-7127
Mailing Address - Fax:715-682-7883
Practice Address - Street 1:72772 ELM STREET
Practice Address - Street 2:
Practice Address - City:ODANAH
Practice Address - State:WI
Practice Address - Zip Code:54861-0055
Practice Address - Country:US
Practice Address - Phone:715-682-7127
Practice Address - Fax:715-682-7883
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251B00000XAgenciesCase Management