Individual
MR. LAWRENCE P FORMAN III
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
R.D.
Contact information
Practice address
US HIGHWAY 491 NORTH, SHIPROCK, NM 87420-0160
(505) 368-6204
(505) 368-6265
Mailing address
PO BOX 160, SHIPROCK, NM 87420-0160
(505) 368-6401
(505) 368-6431
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
Primary
471
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
230062
—
AZ
05
—
G2352
—
NM
Enumeration date
07/03/2006
Last updated
08/14/2008
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