Healthcare Provider Details

I. General information

NPI: 1881437655
Provider Name (Legal Business Name): MY FOREVER FAMILY GROUP HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2024
Last Update Date: 06/18/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 16TH ST SE
NAPLES FL
34117-9424
US

IV. Provider business mailing address

770 16TH ST SE
NAPLES FL
34117-9424
US

V. Phone/Fax

Practice location:
  • Phone: 239-450-4516
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: LISS PEREZ
Title or Position: OWNER
Credential:
Phone: 239-450-4516