Provider Demographics
NPI:1356466379
Name:FORME MEDICAL &BURGESS CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:FORME MEDICAL &BURGESS CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:C
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:256-237-9251
Mailing Address - Street 1:3001 MCCLELLAN BLVD
Mailing Address - Street 2:
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36201-2724
Mailing Address - Country:US
Mailing Address - Phone:256-237-9251
Mailing Address - Fax:256-236-7397
Practice Address - Street 1:3001 MCCLELLAN BLVD
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36201-2724
Practice Address - Country:US
Practice Address - Phone:256-237-9251
Practice Address - Fax:256-236-7397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL915111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51505603OtherBC PROVIDER #
AL51505603OtherBC PROVIDER #
AL051505603Medicare ID - Type UnspecifiedPROVIDER #