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NPI Code Detail

MEDICARE: MR. LAWRENCE P FORMAN III R.D.

MEDICARE: MR. LAWRENCE P FORMAN III R.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1133V00000XRegistered Dietitian471NM

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1174553515
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. LAWRENCE P FORMAN III R.D.
Provider Business Mailing Address
First Line : PO BOX 160
Second Line :
City : SHIPROCK
State : NM
Zip : 87420-0160
Country : US
Telephone Number : 505-368-6401
Fax Number : 505-368-6431
Provider Business Practice Location Address
First Line : US HIGHWAY 491 NORTH
Second Line :
City : SHIPROCK
State : NM
Zip : 87420-0160
Country : US
Telephone Number : 505-368-6204
Fax Number : 505-368-6265
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/03/2006
Last Update Date : 08/14/2008

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