Provider Demographics
NPI:1962543629
Name:REISE, FORREST DAVID (DC,CCSP)
Entity type:Individual
Prefix:DR
First Name:FORREST
Middle Name:DAVID
Last Name:REISE
Suffix:
Gender:M
Credentials:DC,CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 26339
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31221-6339
Mailing Address - Country:US
Mailing Address - Phone:478-475-9990
Mailing Address - Fax:478-475-0661
Practice Address - Street 1:4671 MERCER UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-5611
Practice Address - Country:US
Practice Address - Phone:478-475-9990
Practice Address - Fax:478-475-0661
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR002271111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU22546Medicare UPIN
GAGRP6907Medicare ID - Type Unspecified