Provider Demographics
NPI:1710358148
Name:FOREVER LIVING ASSISTANT CARE HOME CORP.
Entity Type:Organization
Organization Name:FOREVER LIVING ASSISTANT CARE HOME CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRYFENE
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-412-5666
Mailing Address - Street 1:3126 W CARY ST
Mailing Address - Street 2:417
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23221-3504
Mailing Address - Country:US
Mailing Address - Phone:804-836-2641
Mailing Address - Fax:
Practice Address - Street 1:3701 CRESTVIEW RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-8107
Practice Address - Country:US
Practice Address - Phone:804-412-5666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-12
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAALF1104506310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility