Provider Demographics
NPI:1194819219
Name:FORSBERG, KIP W (DC,)
Entity Type:Individual
Prefix:DR
First Name:KIP
Middle Name:W
Last Name:FORSBERG
Suffix:
Gender:M
Credentials:DC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 WATSON BLVD.
Mailing Address - Street 2:
Mailing Address - City:ENDWELL
Mailing Address - State:NY
Mailing Address - Zip Code:13760
Mailing Address - Country:US
Mailing Address - Phone:607-754-4844
Mailing Address - Fax:607-754-6812
Practice Address - Street 1:3003 WATSON BLVD
Practice Address - Street 2:
Practice Address - City:ENDWELL
Practice Address - State:NY
Practice Address - Zip Code:13760-3529
Practice Address - Country:US
Practice Address - Phone:607-754-4844
Practice Address - Fax:607-754-6812
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX002723-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY38174BMedicare ID - Type Unspecified