Healthcare Provider Details

I. General information

NPI: 1265490858
Provider Name (Legal Business Name): DUSTIN RONALD FORNEY AT/PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 09/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8737 UNION CENTRE BLVD
WEST CHESTER OH
45069-4878
US

IV. Provider business mailing address

8737 UNION CENTRE BLVD
WEST CHESTER OH
45069-4878
US

V. Phone/Fax

Practice location:
  • Phone: 513-645-2246
  • Fax: 513-545-2233
Mailing address:
  • Phone: 513-645-2246
  • Fax: 513-545-2233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA.06556
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT2660
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: