Provider Demographics
NPI:1336596956
Name:FORD, MARK C (LMT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:C
Last Name:FORD
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2301 S HURON PKWY STE 1C
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-5133
Mailing Address - Country:US
Mailing Address - Phone:734-262-5106
Mailing Address - Fax:
Practice Address - Street 1:2301 S HURON PKWY STE 1C
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-5133
Practice Address - Country:US
Practice Address - Phone:734-262-5106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL916043225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist