Provider Demographics
NPI:1275080921
Name:FOREVER YOUNG LLC
Entity Type:Organization
Organization Name:FOREVER YOUNG LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ABRAHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-680-5740
Mailing Address - Street 1:4905 LAVISTA RD STE E
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-4409
Mailing Address - Country:US
Mailing Address - Phone:678-606-9833
Mailing Address - Fax:
Practice Address - Street 1:4905 LAVISTA RD STE E
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4409
Practice Address - Country:US
Practice Address - Phone:678-606-9833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PAIN AND WELLNESS CENTERS OF GA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-09
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA00228865174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty