Provider Demographics
NPI:1689367450
Name:FORD, TINA RALINE
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:RALINE
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 1:325 4TH AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25303-1266
Mailing Address - Country:US
Mailing Address - Phone:304-744-5085
Mailing Address - Fax:
Practice Address - Street 1:325 4TH AVE STE 2
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-1266
Practice Address - Country:US
Practice Address - Phone:304-744-5085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-30
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant