MEDICARE: CAROLYN JEAN FORMAN O.M.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	171100000X	Acupuncturist	96196	WV

General Provider Information

NPI Number	:	1831383728
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLYN JEAN FORMAN O.M.D.

Provider Business Mailing Address
First Line	:	110 BROOKLAND CT APT 12
Second Line	:
City	:	WINCHESTER
State	:	VA
Zip	:	22602-6181
Country	:	US
Telephone Number	:	540-550-0306
Fax Number	:

Provider Business Practice Location Address
First Line	:	64 SOMERSET BLVD
Second Line	:
City	:	CHARLES TOWN
State	:	WV
Zip	:	25414-4827
Country	:	US
Telephone Number	:	304-728-5066
Fax Number	:	304-728-5074

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

Provider Enumeration Date	:	09/04/2007
Last Update Date	:	09/04/2007

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