Provider Demographics
NPI:1417116583
Name:FORWARD BOUND MOBILITY, LLC
Entity Type:Organization
Organization Name:FORWARD BOUND MOBILITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:LARRY
Authorized Official - Last Name:GRIMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-376-7479
Mailing Address - Street 1:745 ATLANTA RD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-2745
Mailing Address - Country:US
Mailing Address - Phone:678-455-9220
Mailing Address - Fax:678-455-9250
Practice Address - Street 1:745 ATLANTA RD
Practice Address - Street 2:SUITE 109
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2745
Practice Address - Country:US
Practice Address - Phone:678-455-9220
Practice Address - Fax:678-455-9250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-04
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA213601448AMedicaid
6123530001Medicare NSC