Healthcare Provider Details

I. General information

NPI: 1598465221
Provider Name (Legal Business Name): FOREVER 29 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2023
Last Update Date: 05/09/2025
Certification Date: 05/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10416 MORNING STAR DR NE
ALBUQUERQUE NM
87111-7539
US

IV. Provider business mailing address

PO BOX 90644
ALBUQUERQUE NM
87199-0644
US

V. Phone/Fax

Practice location:
  • Phone: 214-227-2457
  • Fax: 214-764-0880
Mailing address:
  • Phone: 214-227-2457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KELLY V RIVERA
Title or Position: OWNER / PROVIDER
Credential: NP
Phone: 214-227-2457