Provider Demographics
NPI:1952810814
Name:FORD, NACHA LATRICE (LAC)
Entity Type:Individual
Prefix:
First Name:NACHA
Middle Name:LATRICE
Last Name:FORD
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2997 TURNBERRY LN
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:IL
Mailing Address - Zip Code:60538-4109
Mailing Address - Country:US
Mailing Address - Phone:312-608-2063
Mailing Address - Fax:
Practice Address - Street 1:2677 ROUTE 34 STE C
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-8660
Practice Address - Country:US
Practice Address - Phone:331-245-6664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-22
Last Update Date:2017-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198001327171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist