Provider Demographics
NPI:1477204527
Name:WOLFORD, VANCE MITCHELL SR (N/A)
Entity Type:Individual
Prefix:MR
First Name:VANCE
Middle Name:MITCHELL
Last Name:WOLFORD
Suffix:SR
Gender:M
Credentials:N/A
Other - Prefix:MR
Other - First Name:VANCE
Other - Middle Name:MITCHELL
Other - Last Name:WOLFORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:N/A
Mailing Address - Street 1:PO BOX 942
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-0942
Mailing Address - Country:US
Mailing Address - Phone:907-399-7399
Mailing Address - Fax:
Practice Address - Street 1:302 RAILWAY AVE
Practice Address - Street 2:
Practice Address - City:SEWARD
Practice Address - State:AK
Practice Address - Zip Code:99664
Practice Address - Country:US
Practice Address - Phone:907-224-5257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician