Healthcare Provider Details

I. General information

NPI: 1205428992
Provider Name (Legal Business Name): HAZEL FORMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2021
Last Update Date: 05/12/2022
Certification Date: 05/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 MOODY ST
GREENSBORO NC
27401-4217
US

IV. Provider business mailing address

1200 MOODY ST
GREENSBORO NC
27401-4217
US

V. Phone/Fax

Practice location:
  • Phone: 336-860-4060
  • Fax: 336-937-9157
Mailing address:
  • Phone: 336-709-6601
  • Fax: 336-937-9157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License NumberFCL-041-081
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License NumberFCL-041-082
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: