Healthcare Provider Details

I. General information

NPI: 1578968772
Provider Name (Legal Business Name): MR. FORREST PETTY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2014
Last Update Date: 10/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3223 E SILVER SPRINGS BLVD
OCALA FL
34470-6409
US

IV. Provider business mailing address

3223 E SILVER SPRINGS BLVD
OCALA FL
34470-6409
US

V. Phone/Fax

Practice location:
  • Phone: 352-694-5003
  • Fax: 352-694-6003
Mailing address:
  • Phone: 352-694-5003
  • Fax: 352-694-6003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberAS4967
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: