Provider Demographics
NPI:1205071495
Name:FORREST, MICHAEL ROBERT (LMT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROBERT
Last Name:FORREST
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1386 E 100 S
Mailing Address - Street 2:SUITE F
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-2141
Mailing Address - Country:US
Mailing Address - Phone:435-215-3480
Mailing Address - Fax:
Practice Address - Street 1:1386 E 100 S
Practice Address - Street 2:SUITE F
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-2141
Practice Address - Country:US
Practice Address - Phone:435-215-3480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-03
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6366483-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist