Provider Demographics
NPI:1871936716
Name:FOREVER YOUTHFUL ADULT EDUCATIONAL AND RECREATIONAL CENTER
Entity type:Organization
Organization Name:FOREVER YOUTHFUL ADULT EDUCATIONAL AND RECREATIONAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MILDRED
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:662-754-3114
Mailing Address - Street 1:149 EAST PEELER AVENUE
Mailing Address - Street 2:PO BOX 1053
Mailing Address - City:SHAW
Mailing Address - State:MS
Mailing Address - Zip Code:38733-1053
Mailing Address - Country:US
Mailing Address - Phone:662-754-3114
Mailing Address - Fax:662-754-3055
Practice Address - Street 1:149 EAST PEELER AVE
Practice Address - Street 2:
Practice Address - City:SHAW
Practice Address - State:MS
Practice Address - Zip Code:38733-1053
Practice Address - Country:US
Practice Address - Phone:662-754-3114
Practice Address - Fax:662-754-3055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-10
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care