Provider Demographics
NPI:1366642225
Name:FOREST MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:FOREST MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NINA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BREDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-559-1866
Mailing Address - Street 1:3803 S BASCOM AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-7317
Mailing Address - Country:US
Mailing Address - Phone:408-559-1866
Mailing Address - Fax:408-559-1868
Practice Address - Street 1:3803 S BASCOM AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-7317
Practice Address - Country:US
Practice Address - Phone:408-559-1866
Practice Address - Fax:408-559-1868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA24232174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A249840Medicare UPIN