=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831464411
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOREVER CARE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2012
-----------------------------------------------------
Last Update Date | 03/15/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2662 RAINBOW CREEK DR
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30034-2155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-348-8353
-----------------------------------------------------
Fax | 404-973-0289
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6654 HAWES DR
-----------------------------------------------------
City | LITHONIA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30058-4631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-348-8353
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO / DIRECTOR
-----------------------------------------------------
Name | MRS. TANISHA FARQUHARSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-348-8353
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number | CLA000917
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------