Provider Demographics
NPI:1154091601
Name:FORNECKER, MIKE
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:FORNECKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3935 SUNNYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKINGHAM
Mailing Address - State:VA
Mailing Address - Zip Code:22801-2328
Mailing Address - Country:US
Mailing Address - Phone:540-568-8200
Mailing Address - Fax:
Practice Address - Street 1:3935 SUNNYSIDE DR
Practice Address - Street 2:
Practice Address - City:ROCKINGHAM
Practice Address - State:VA
Practice Address - Zip Code:22801-2328
Practice Address - Country:US
Practice Address - Phone:540-568-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist