Provider Demographics
NPI:1356612287
Name:FORD, TRACY VERNEIL
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:VERNEIL
Last Name:FORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:VERNEIL
Other - Last Name:JACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2225 SPRUCE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-1954
Mailing Address - Country:US
Mailing Address - Phone:702-809-4935
Mailing Address - Fax:702-369-5605
Practice Address - Street 1:2225 SPRUCE AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-1954
Practice Address - Country:US
Practice Address - Phone:702-809-4935
Practice Address - Fax:702-369-5605
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-24
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner