Provider Demographics
NPI:1629336581
Name:FORKU, BOONEGROSS
Entity Type:Individual
Prefix:
First Name:BOONEGROSS
Middle Name:
Last Name:FORKU
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 1:13832 CASTLE BLVD
Mailing Address - Street 2:APT 104
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-7368
Mailing Address - Country:US
Mailing Address - Phone:202-558-0278
Mailing Address - Fax:
Practice Address - Street 1:13832 CASTLE BLVD
Practice Address - Street 2:APT 104
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-7368
Practice Address - Country:US
Practice Address - Phone:202-558-0278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide