Provider Demographics
NPI:1760831317
Name:FORD, DANIEL J (SUDCC)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:J
Last Name:FORD
Suffix:
Gender:M
Credentials:SUDCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3819 PRINCE ANDREW DR
Mailing Address - Street 2:
Mailing Address - City:RIVERBANK
Mailing Address - State:CA
Mailing Address - Zip Code:95367-3094
Mailing Address - Country:US
Mailing Address - Phone:209-409-5089
Mailing Address - Fax:
Practice Address - Street 1:800 SCENIC DR BLDG F
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-6131
Practice Address - Country:US
Practice Address - Phone:209-661-1596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-05
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA374700000XMedicaid