Provider Demographics
NPI:1639372709
Name:PECHA, FORREST Q (MS, ATC, LAT, OTC)
Entity Type:Individual
Prefix:
First Name:FORREST
Middle Name:Q
Last Name:PECHA
Suffix:
Gender:M
Credentials:MS, ATC, LAT, OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12664 N 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-5061
Mailing Address - Country:US
Mailing Address - Phone:208-908-1236
Mailing Address - Fax:
Practice Address - Street 1:1109 W MYRTLE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6970
Practice Address - Country:US
Practice Address - Phone:208-489-4331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0011692255A2300X
GA02 5855246ZS0410X
IDAT-3912255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist