Healthcare Provider Details

I. General information

NPI: 1366194649
Provider Name (Legal Business Name): FOREVER YOUNG DIAGNOSTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2022
Last Update Date: 02/18/2022
Certification Date: 02/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 LITHIA PINECREST RD STE H
BRANDON FL
33511-5300
US

IV. Provider business mailing address

3848 SUN CITY CENTER BLVD # 104-49
SUN CITY CENTER FL
33573-6843
US

V. Phone/Fax

Practice location:
  • Phone: 813-857-8556
  • Fax:
Mailing address:
  • Phone: 813-857-8556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: ZARANDA YOUNG
Title or Position: ADMIN
Credential:
Phone: 813-857-8556