MEDICARE: FOREVER HEAVENLY HOSPICE INC

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	251G00000X	Community Based Hospice Care Agency

General Provider Information

NPI Number	:	1710293196
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOREVER HEAVENLY HOSPICE INC

Provider Business Mailing Address
First Line	:	10523 BURBANK BLVD
Second Line	:	STE 203
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91601-2233
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10523 BURBANK BLVD
Second Line	:	STE 203
City	:	NORTH HOLLYWOOD
State	:	CA
Zip	:	91601-2233
Country	:	US
Telephone Number	:	818-402-2500
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	ROSHANAK KHADEM
Credential	:
Telephone Number	:	818-402-2500

Provider Enumeration Date	:	08/24/2010
Last Update Date	:	08/24/2010

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