Provider Demographics
NPI:1104005735
Name:FORD HOME
Entity Type:Organization
Organization Name:FORD HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:OLIVER
Authorized Official - Middle Name:
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-381-0125
Mailing Address - Street 1:PO BOX 5182
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-1182
Mailing Address - Country:US
Mailing Address - Phone:910-937-6000
Mailing Address - Fax:910-324-2725
Practice Address - Street 1:311 BRENTWOOD AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-5405
Practice Address - Country:US
Practice Address - Phone:910-324-2787
Practice Address - Fax:910-324-2725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL 067-167251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCMHL 067-167Medicaid