Provider Demographics
NPI:1598465221
Name:FOREVER 29 LLC
Entity Type:Organization
Organization Name:FOREVER 29 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:505-463-1017
Mailing Address - Street 1:8905 CIELITO LINDO CT NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-1572
Mailing Address - Country:US
Mailing Address - Phone:505-463-1017
Mailing Address - Fax:
Practice Address - Street 1:8905 CIELITO LINDO CT NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-1572
Practice Address - Country:US
Practice Address - Phone:505-463-1017
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-10
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First AssistantGroup - Multi-Specialty