Provider Demographics
NPI:1255944559
Name:THE CLINIC AT THE FORGING PLACE
Entity type:Organization
Organization Name:THE CLINIC AT THE FORGING PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING/ OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:FERGESON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-777-8510
Mailing Address - Street 1:1302 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-4543
Mailing Address - Country:US
Mailing Address - Phone:479-310-9096
Mailing Address - Fax:479-777-8510
Practice Address - Street 1:1302 CHERRY ST
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-4543
Practice Address - Country:US
Practice Address - Phone:479-310-9096
Practice Address - Fax:479-777-8510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-26
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty