Provider Demographics
NPI:1457582694
Name:FORD, BLAINE ALAN (DC)
Entity Type:Individual
Prefix:DR
First Name:BLAINE
Middle Name:ALAN
Last Name:FORD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:UT
Mailing Address - Zip Code:84737-1949
Mailing Address - Country:US
Mailing Address - Phone:435-635-9444
Mailing Address - Fax:435-635-8148
Practice Address - Street 1:11S MAIN ST
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:UT
Practice Address - Zip Code:84737-1949
Practice Address - Country:US
Practice Address - Phone:435-635-9444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-05
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3346-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT6357690001Medicare NSC