Provider Demographics
NPI:1265460570
Name:FORMAN, ERIC DEAN (DC)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:DEAN
Last Name:FORMAN
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 1:404 N GALENA AVE
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-2115
Mailing Address - Country:US
Mailing Address - Phone:815-288-6683
Mailing Address - Fax:815-288-4892
Practice Address - Street 1:404 N GALENA AVE
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-2115
Practice Address - Country:US
Practice Address - Phone:815-288-6683
Practice Address - Fax:815-288-4892
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor