Basic Information
| Provider Information | |||||||||
| NPI: | 1114378494 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORD | ||||||||
| FirstName: | HALEY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| OtherLastName: | MOORE | ||||||||
| OtherFirstName: | HALEY | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 441 | ||||||||
| Address2: | 500 HIGHWAY 61 J N | ||||||||
| City: | HAYTI | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638510441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733592600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 HIGHWAY J # 61JN | ||||||||
| Address2: | |||||||||
| City: | HAYTI | ||||||||
| State: | MO | ||||||||
| PostalCode: | 638511200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733592600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2016 | ||||||||
| LastUpdateDate: | 06/28/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247200000X | Y | Technologists, Technicians & Other Technical Service Providers | Technician, Other |
No ID Information.