=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386219566
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC VON FORSBERG I-MD, TND, PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2021
-----------------------------------------------------
Last Update Date | 12/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21435 WILCOX RD
-----------------------------------------------------
City | RED BLUFF
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96080-7962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-567-5094
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 41 W HIGHWAY 14 # 1671
-----------------------------------------------------
City | SPEARFISH
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57783-1148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-602-3099
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 175F00000X
-----------------------------------------------------
Taxonomy Name | Naturopath
-----------------------------------------------------
License Number | 4522253
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 146M00000X
-----------------------------------------------------
Taxonomy Name | Intermediate Emergency Medical Technician
-----------------------------------------------------
License Number | A2038449
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 164X00000X
-----------------------------------------------------
Taxonomy Name | Licensed Vocational Nurse
-----------------------------------------------------
License Number | 191092
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 171400000X
-----------------------------------------------------
Taxonomy Name | Health & Wellness Coach
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------