MEDICARE: FOREVER PLACE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1356948954
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOREVER PLACE LLC

Provider Business Mailing Address
First Line	:	4200 N PEBBLE CREEK PKWY APT 2069
Second Line	:
City	:	GOODYEAR
State	:	AZ
Zip	:	85395-9028
Country	:	US
Telephone Number	:	567-225-4008
Fax Number	:

Provider Business Practice Location Address
First Line	:	4200 N PEBBLE CREEK PKWY APT 2069
Second Line	:
City	:	GOODYEAR
State	:	AZ
Zip	:	85395-9028
Country	:	US
Telephone Number	:	567-225-4008
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DIRECTOR
Name	:	MS. LACHONIQUIE EVANS
Credential	:
Telephone Number	:	567-225-4008

Provider Enumeration Date	:	10/06/2020
Last Update Date	:	10/06/2020

Similar Medicare Providers

1053796383 — GRACE MARY RUETTINGER PA
Practice Location Address:

13471 W CORNERSTONE BLVD
GOODYEAR, AZ
85395-2713

Practice Phone: 480-964-2273
Practice Fax:

1710857917 — FND HEALING CENTER PLLC
Practice Location Address:

4649 N 177TH DR
GOODYEAR, AZ
85395-4403

Practice Phone: 480-434-1272
Practice Fax:

1689501652 — FOCUSED HEALING & WELLNESS
Practice Location Address:

15150 W PARK PL STE 215
GOODYEAR, AZ
85395-2386

Practice Phone: 623-248-0297
Practice Fax: 623-248-0299

1487581112 — COLLIN MCCLELLAN
Practice Location Address:

15260 W MCDOWELL RD
GOODYEAR, AZ
85395-2530

Practice Phone: 623-207-7838
Practice Fax:

1831026442 — ZACHARY MARTINEZ
Practice Location Address:

13677 W MCDOWELL RD
GOODYEAR, AZ
85395-2635

Practice Phone: 623-882-1500
Practice Fax:

1205763828 — JENNY MERCER LAC
Practice Location Address:

15150 W PARK PL # 2034
GOODYEAR, AZ
85395-2385

Practice Phone: 623-759-0290
Practice Fax:

Directions to “FOREVER PLACE LLC ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.