=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477313351
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOREVERSONYA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2024
-----------------------------------------------------
Last Update Date | 03/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11602 GARDEN DR
-----------------------------------------------------
City | GARDEN GROVE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92840-1555
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-737-9457
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6552 CRESCENT AVE
-----------------------------------------------------
City | BUENA PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90620-3752
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-737-9457
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSEE
-----------------------------------------------------
Name | YOUSEF FAKHOURI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 714-737-9457
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------