Basic Information
| Provider Information | |||||||||
| NPI: | 1972008126 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ASHFORD | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | L.A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5601 DOMINGO RD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871081610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059980450 | ||||||||
| FaxNumber: | 5052689967 | ||||||||
| Practice Location | |||||||||
| Address1: | 5601 DOMINGO RD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871081610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059980450 | ||||||||
| FaxNumber: | 5052689967 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2018 | ||||||||
| LastUpdateDate: | 03/29/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 373H00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Related Providers | Day Training/Habilitation Specialist |
No ID Information.