Provider Demographics
NPI:1568061018
Name:FORDERER, KEVIN RAY
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:RAY
Last Name:FORDERER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13801 10TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-3827
Mailing Address - Country:US
Mailing Address - Phone:701-527-2282
Mailing Address - Fax:
Practice Address - Street 1:13801 10TH AVE SE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-3827
Practice Address - Country:US
Practice Address - Phone:701-527-2282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-25
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant