Healthcare Provider Details

I. General information

NPI: 1558961227
Provider Name (Legal Business Name): MARK DAVID FORESTER BS CCSH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2020
Last Update Date: 10/30/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1822 N SYLVANIA AVE
FORT WORTH TX
76111-2755
US

IV. Provider business mailing address

1822 N SYLVANIA AVE
FORT WORTH TX
76111-2755
US

V. Phone/Fax

Practice location:
  • Phone: 817-379-6334
  • Fax: 817-379-6335
Mailing address:
  • Phone: 817-379-6334
  • Fax: 817-379-6335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number1081
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number1081
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: