Healthcare Provider Details

I. General information

NPI: 1255661732
Provider Name (Legal Business Name): LEE A FORESTIERE MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2010
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 W 40TH AVE STE 403
PINE BLUFF AR
71603-6365
US

IV. Provider business mailing address

1609 W 40TH AVE STE 403
PINE BLUFF AR
71603-6365
US

V. Phone/Fax

Practice location:
  • Phone: 870-534-4188
  • Fax: 870-534-7964
Mailing address:
  • Phone: 870-534-4188
  • Fax: 870-534-7964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberC4813
License Number StateAR

VIII. Authorized Official

Name: RENEE BOGY
Title or Position: OFFICE MANAGER
Credential:
Phone: 870-534-4188