Basic Information
Provider Information | |||||||||
NPI: | 1174553515 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FORMAN | ||||||||
FirstName: | LAWRENCE | ||||||||
MiddleName: | P | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: | III | ||||||||
Credential: | R.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FORMAN | ||||||||
OtherFirstName: | LARRY | ||||||||
OtherMiddleName: | P | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | R.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 160 | ||||||||
Address2: |   | ||||||||
City: | SHIPROCK | ||||||||
State: | NM | ||||||||
PostalCode: | 874200160 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5053686401 | ||||||||
FaxNumber: | 5053686431 | ||||||||
Practice Location | |||||||||
Address1: | US HIGHWAY 491 NORTH | ||||||||
Address2: |   | ||||||||
City: | SHIPROCK | ||||||||
State: | NM | ||||||||
PostalCode: | 874200160 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5053686204 | ||||||||
FaxNumber: | 5053686265 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/03/2006 | ||||||||
LastUpdateDate: | 08/14/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 471 | NM | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
ID Information
ID | Type | State | Issuer | Description | G2352 | 05 | NM |   | MEDICAID | 230062 | 05 | AZ |   | MEDICAID |