Provider Demographics
NPI:1891079976
Name:FORD, MONTIE DALE (CDC 1)
Entity Type:Individual
Prefix:
First Name:MONTIE
Middle Name:DALE
Last Name:FORD
Suffix:
Gender:M
Credentials:CDC 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 MARIKA RD
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-5521
Mailing Address - Country:US
Mailing Address - Phone:907-474-0890
Mailing Address - Fax:907-474-3621
Practice Address - Street 1:1825 MARIKA RD
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-5521
Practice Address - Country:US
Practice Address - Phone:907-474-0890
Practice Address - Fax:907-474-3621
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDA3237Medicaid
AKMH3237Medicaid