=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710358148
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOREVER LIVING ASSISTANT CARE HOME CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2015
-----------------------------------------------------
Last Update Date | 10/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3701 CRESTVIEW RD
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23223-8107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-412-5666
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3126 W CARY ST 417
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23221-3504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-836-2641
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | TRYFENE SCOTT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 804-412-5666
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | ALF1104506
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------