Healthcare Provider Details

I. General information

NPI: 1871936716
Provider Name (Legal Business Name): FOREVER YOUTHFUL ADULT EDUCATIONAL AND RECREATIONAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2013
Last Update Date: 04/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 EAST PEELER AVE
SHAW MS
38733-1053
US

IV. Provider business mailing address

149 EAST PEELER AVENUE PO BOX 1053
SHAW MS
38733-1053
US

V. Phone/Fax

Practice location:
  • Phone: 662-754-3114
  • Fax: 662-754-3055
Mailing address:
  • Phone: 662-754-3114
  • Fax: 662-754-3055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number StateMS

VIII. Authorized Official

Name: MRS. MILDRED TAYLOR
Title or Position: ADMINISTRATOR
Credential: R.N
Phone: 662-754-3114