Provider Demographics
NPI:1932223617
Name:FORD HOME
Entity Type:Organization
Organization Name:FORD HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:OLIVER
Authorized Official - Middle Name:WENDELL
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:910-381-0125
Mailing Address - Street 1:PO BOX 5182
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-1182
Mailing Address - Country:US
Mailing Address - Phone:910-937-6000
Mailing Address - Fax:910-324-2725
Practice Address - Street 1:510 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-4706
Practice Address - Country:US
Practice Address - Phone:910-937-6000
Practice Address - Fax:910-324-2725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-067-150251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408486Medicaid