Healthcare Provider Details

I. General information

NPI: 1538847991
Provider Name (Legal Business Name): FOR 4EVERBLESSED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2023
Last Update Date: 07/06/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3605 COURTLEIGH DR
RANDALLSTOWN MD
21133-4806
US

IV. Provider business mailing address

8747 FONTANA LN
BALTIMORE MD
21237-2300
US

V. Phone/Fax

Practice location:
  • Phone: 443-392-6934
  • Fax:
Mailing address:
  • Phone: 443-392-6934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: KEYANNA D WILLIAMS
Title or Position: BILLING COORDINATOR
Credential:
Phone: 443-392-6934