=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629257019
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | F O R M E MEDICAL & REHAB CENTER OF FREMONT, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2007
-----------------------------------------------------
Last Update Date | 11/22/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 728 N STONE ST
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43420-1535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-334-7600
-----------------------------------------------------
Fax | 419-334-7640
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 728 N STONE ST
-----------------------------------------------------
City | FREMONT
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43420-1535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-334-7600
-----------------------------------------------------
Fax | 419-334-7640
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | DR. PAUL LYNN SILCOX
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 419-334-7600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1523
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------