Provider Demographics
NPI:1942623194
Name:FORDE, JUSTIN (DC)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:FORDE
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 1:1900 PASS RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-5100
Mailing Address - Country:US
Mailing Address - Phone:228-864-6159
Mailing Address - Fax:228-864-3186
Practice Address - Street 1:1900 PASS RD
Practice Address - Street 2:SUITE D
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-5100
Practice Address - Country:US
Practice Address - Phone:228-864-6159
Practice Address - Fax:228-864-3186
Is Sole Proprietor?:No
Enumeration Date:2014-01-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1218111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor