Provider Demographics
NPI:1619333481
Name:FOREVER YOUNG
Entity Type:Organization
Organization Name:FOREVER YOUNG
Other - Org Name:PROFESSIONAL URGENT CARE, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:LARUE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:417-206-0900
Mailing Address - Street 1:6031 N MAIN STREET RD
Mailing Address - Street 2:#395
Mailing Address - City:WEBB CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64870-7219
Mailing Address - Country:US
Mailing Address - Phone:417-206-0900
Mailing Address - Fax:417-206-0907
Practice Address - Street 1:6055 N MAIN STREET RD
Practice Address - Street 2:
Practice Address - City:WEBB CITY
Practice Address - State:MO
Practice Address - Zip Code:64870-7219
Practice Address - Country:US
Practice Address - Phone:417-206-0900
Practice Address - Fax:417-206-0907
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROFESSIONAL URGENT CARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-01-11
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9J48261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center