Provider Demographics
NPI:1073650446
Name:FOREVER YOUNG SECURED COMMUNITY
Entity Type:Organization
Organization Name:FOREVER YOUNG SECURED COMMUNITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ONWER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALMA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:WESTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-527-0258
Mailing Address - Street 1:1133 CHESTNUT WOOD DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-1890
Mailing Address - Country:US
Mailing Address - Phone:910-527-0258
Mailing Address - Fax:910-864-2548
Practice Address - Street 1:181 BOSTIC RD
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-6101
Practice Address - Country:US
Practice Address - Phone:910-527-0258
Practice Address - Fax:910-864-2548
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOREVER YOUNG GROUP CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-01
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL047101320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6604011Medicaid