Basic Information
| Provider Information | |||||||||
| NPI: | 1053331694 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HENDRY COUNTY HOSPITAL AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DR. JAMES D. FORBES FAMILY CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 W SAGAMORE AVE | ||||||||
| Address2: | |||||||||
| City: | CLEWISTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334403514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8639023032 | ||||||||
| FaxNumber: | 8639836655 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W SAGAMORE AVE | ||||||||
| Address2: | |||||||||
| City: | CLEWISTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334403514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8639023032 | ||||||||
| FaxNumber: | 8639836655 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 10/23/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BEASLEY | ||||||||
| AuthorizedOfficialFirstName: | LYNN | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8639023076 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | 3995 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 253668401 | 05 | FL | MEDICAID |