Provider Demographics
NPI:1790765436
Name:FORREST, RICHARD BOYSEN (DC)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:BOYSEN
Last Name:FORREST
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 BREEZY POINT DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732-3636
Mailing Address - Country:US
Mailing Address - Phone:563-241-1074
Mailing Address - Fax:
Practice Address - Street 1:80 23RD AVE N
Practice Address - Street 2:FORREST CHIROPRACTIC OFFICES
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-3636
Practice Address - Country:US
Practice Address - Phone:563-242-8026
Practice Address - Fax:563-242-0016
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA04908111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0196816Medicaid
IA12819OtherGROUP #
IA350045382OtherRR MEDICARE
IACJ5186OtherRR MEDICARE GROUP #
IA45-3076673OtherFEDERAL TAX ID #
IA04908OtherIA LICENSE #
IA04899OtherBCBS
IAT91059Medicare UPIN
IA12819Medicare PIN
IA04899OtherBCBS