Provider Demographics
NPI:1245390343
Name:F O R M E MEDICAL AND REHAB CENTER OF WARREN INC
Entity Type:Organization
Organization Name:F O R M E MEDICAL AND REHAB CENTER OF WARREN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NESTOR
Authorized Official - Middle Name:A
Authorized Official - Last Name:STYCHNO
Authorized Official - Suffix:
Authorized Official - Credentials:DM, DC
Authorized Official - Phone:330-544-3737
Mailing Address - Street 1:2103 NILES CORTLAND RD SE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-3067
Mailing Address - Country:US
Mailing Address - Phone:330-544-3737
Mailing Address - Fax:330-544-3904
Practice Address - Street 1:2103 NILES CORTLAND RD SE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-3067
Practice Address - Country:US
Practice Address - Phone:330-544-3737
Practice Address - Fax:330-544-3904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH139111N00000X
OH2393111N00000X
OH35050935207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0608444Medicaid
OH2459129Medicaid
OH0119473Medicaid
OHT46377Medicare UPIN
OH0119473Medicaid
OH0608444Medicaid