Provider Demographics
NPI:1629257019
Name:F O R M E MEDICAL & REHAB CENTER OF FREMONT, INC
Entity Type:Organization
Organization Name:F O R M E MEDICAL & REHAB CENTER OF FREMONT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:419-334-7600
Mailing Address - Street 1:728 N STONE ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-1535
Mailing Address - Country:US
Mailing Address - Phone:419-334-7600
Mailing Address - Fax:419-334-7640
Practice Address - Street 1:728 N STONE ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-1535
Practice Address - Country:US
Practice Address - Phone:419-334-7600
Practice Address - Fax:419-334-7640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-01
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1523111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH350022051OtherMEDICARE RAIL ROAD
OH2511660Medicaid
OH350022051OtherMEDICARE RAIL ROAD
OH5281760001Medicare NSC