Healthcare Provider Details

I. General information

NPI: 1619014073
Provider Name (Legal Business Name): FOREVER YOUNG GROUP CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 04/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 COMET CIR
FAYETTEVILLE NC
28314-0400
US

IV. Provider business mailing address

1133 CHESTNUT WOOD DR
FAYETTEVILLE NC
28314-1890
US

V. Phone/Fax

Practice location:
  • Phone: 910-527-0258
  • Fax: 910-864-2548
Mailing address:
  • Phone: 910-527-0258
  • Fax: 910-864-2548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberMHL026678
License Number StateNC

VIII. Authorized Official

Name: MR. ALMA JEAN WESTON
Title or Position: OWNER
Credential: BA
Phone: 910-527-0258