Provider Demographics
NPI:1780989467
Name:AMY H FORESTE PLLC
Entity type:Organization
Organization Name:AMY H FORESTE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF OPTOMETRY
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:H
Authorized Official - Last Name:CHAMP
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:928-541-0615
Mailing Address - Street 1:2053 PLATEAU
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-2169
Mailing Address - Country:US
Mailing Address - Phone:928-541-0615
Mailing Address - Fax:
Practice Address - Street 1:3400 GATEWAY BLVD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86303-6848
Practice Address - Country:US
Practice Address - Phone:928-778-4402
Practice Address - Fax:928-778-4402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ967152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty