Healthcare Provider Details

I. General information

NPI: 1245390343
Provider Name (Legal Business Name): F O R M E MEDICAL AND REHAB CENTER OF WARREN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 09/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2103 NILES CORTLAND RD SE
WARREN OH
44484-3067
US

IV. Provider business mailing address

2103 NILES CORTLAND RD SE
WARREN OH
44484-3067
US

V. Phone/Fax

Practice location:
  • Phone: 330-544-3737
  • Fax: 330-544-3904
Mailing address:
  • Phone: 330-544-3737
  • Fax: 330-544-3904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2393
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number35050935
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number139
License Number StateOH

VIII. Authorized Official

Name: NESTOR A STYCHNO
Title or Position: PRESIDENT
Credential: D.M., D.C.
Phone: 330-544-3737