Healthcare Provider Details

I. General information

NPI: 1407810179
Provider Name (Legal Business Name): FORREST E HENRY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 02/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 DEMOSS STREET
LORDSBURG NM
88045-2618
US

IV. Provider business mailing address

530 DEMOSS STREET
LORDSBURG NM
88045-2618
US

V. Phone/Fax

Practice location:
  • Phone: 575-542-2313
  • Fax: 575-542-2388
Mailing address:
  • Phone: 575-542-2313
  • Fax: 575-542-2388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberT-252
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA-1382-06
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: