Healthcare Provider Details

I. General information

NPI: 1114503190
Provider Name (Legal Business Name): FOREVER YOUNG MENS HEALTH CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2021
Last Update Date: 05/11/2022
Certification Date: 05/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8837 LORRAINE RD STE B
GULFPORT MS
39503-5042
US

IV. Provider business mailing address

8837 LORRAINE RD STE B
GULFPORT MS
39503-5042
US

V. Phone/Fax

Practice location:
  • Phone: 228-669-7293
  • Fax:
Mailing address:
  • Phone: 228-669-7293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. KENDRICK MCCARTY
Title or Position: OWNER
Credential: FNP
Phone: 228-669-7293