Provider Demographics
NPI:1316233224
Name:FORD, RODNEY DEAN JR (ATC)
Entity type:Individual
Prefix:MR
First Name:RODNEY
Middle Name:DEAN
Last Name:FORD
Suffix:JR
Gender:M
Credentials:ATC
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:4550 MEMORIAL DR. OFFICE CENTER ONE STE G100
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5372
Mailing Address - Country:US
Mailing Address - Phone:618-236-2246
Mailing Address - Fax:618-236-2315
Practice Address - Street 1:4550 MEMORIAL DR. OFFICE CENTER ONE STE G100
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62226-5372
Practice Address - Country:US
Practice Address - Phone:618-236-2246
Practice Address - Fax:618-236-2315
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0012232255A2300X
MO20001646122255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer