Provider Demographics
NPI:1407264328
Name:FORGET ME NOT ULTRASOUND
Entity Type:Organization
Organization Name:FORGET ME NOT ULTRASOUND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROXANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:ERTEL
Authorized Official - Suffix:
Authorized Official - Credentials:BA,CNMT,RDMS
Authorized Official - Phone:716-984-4484
Mailing Address - Street 1:3346 DUNDEE LOOP
Mailing Address - Street 2:
Mailing Address - City:NORTH POLE
Mailing Address - State:AK
Mailing Address - Zip Code:99705-7481
Mailing Address - Country:US
Mailing Address - Phone:907-488-1995
Mailing Address - Fax:
Practice Address - Street 1:2054 #30TH AVENUE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5720
Practice Address - Country:US
Practice Address - Phone:907-987-7523
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-23
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center