Provider Demographics
NPI:1457482200
Name:FORDE, VANCE
Entity Type:Individual
Prefix:MR
First Name:VANCE
Middle Name:
Last Name:FORDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:443 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-6523
Mailing Address - Country:US
Mailing Address - Phone:352-589-5595
Mailing Address - Fax:352-589-5747
Practice Address - Street 1:443 PLAZA DR
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-6523
Practice Address - Country:US
Practice Address - Phone:352-589-5595
Practice Address - Fax:352-589-5747
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15418225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant