Healthcare Provider Details

I. General information

NPI: 1063866424
Provider Name (Legal Business Name): KIM FORGIONE OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2016
Last Update Date: 06/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 NE 162ND AVE STE D103
VANCOUVER WA
98684
US

IV. Provider business mailing address

1514 SW 6TH ST
BATTLE GROUND WA
98604-3000
US

V. Phone/Fax

Practice location:
  • Phone: 360-702-8184
  • Fax:
Mailing address:
  • Phone: 360-702-8184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4290ATI
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOD60850778
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: