Provider Demographics
NPI:1346025285
Name:FOREVERMORE MING BODY & SOUL
Entity Type:Organization
Organization Name:FOREVERMORE MING BODY & SOUL
Other - Org Name:FOREVERMORE HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MENTAL HEALTH PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEMITRIUS
Authorized Official - Middle Name:
Authorized Official - Last Name:BRACKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-766-5999
Mailing Address - Street 1:411 N BLUFF ST APT 11
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-7295
Mailing Address - Country:US
Mailing Address - Phone:815-766-5999
Mailing Address - Fax:
Practice Address - Street 1:1260 W JEFFERSON ST STE 100
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6869
Practice Address - Country:US
Practice Address - Phone:815-766-5999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-29
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health