Healthcare Provider Details

I. General information

NPI: 1891239786
Provider Name (Legal Business Name): FOREVER LIVING RESIDENCE HOME CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2016
Last Update Date: 12/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1608 AZTEC WAY
LAS VEGAS NV
89169-3168
US

IV. Provider business mailing address

1608 AZTEC WAY
LAS VEGAS NV
89169-3168
US

V. Phone/Fax

Practice location:
  • Phone: 702-990-1624
  • Fax:
Mailing address:
  • Phone: 702-990-1624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number7507 AGC-6
License Number StateNV

VIII. Authorized Official

Name: VIRGINIA ESCOBAR
Title or Position: OWNER
Credential:
Phone: 702-331-1695