MEDICARE: MR. MARK DAVID FORESTER BS CCSH

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
1	246Z00000X	Other Specialist/Technologist	1081	TX
2	174H00000X	Health Educator	1081	TX

General Provider Information

NPI Number	:	1558961227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK DAVID FORESTER BS CCSH

Provider Business Mailing Address
First Line	:	1822 N SYLVANIA AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76111-2755
Country	:	US
Telephone Number	:	817-379-6334
Fax Number	:	817-379-6335

Provider Business Practice Location Address
First Line	:	1822 N SYLVANIA AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76111-2755
Country	:	US
Telephone Number	:	817-379-6334
Fax Number	:	817-379-6335

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/30/2020
Last Update Date	:	10/30/2020

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