MEDICARE: CHARLOTTE FORGIE O.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
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1639423585
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLOTTE FORGIE O.D.

Provider Business Mailing Address
First Line	:	2043 COLLEGE WAY
Second Line	:
City	:	FOREST GROVE
State	:	OR
Zip	:	97116-1756
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2993 MAIN ST
Second Line	:
City	:	FOREST GROVE
State	:	OR
Zip	:	97116-8650
Country	:	US
Telephone Number	:	503-840-0524
Fax Number	:

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

Provider Enumeration Date	:	10/30/2012
Last Update Date	:	02/02/2013

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