1871936716 NPI number — FOREVER YOUTHFUL ADULT EDUCATIONAL AND RECREATIONAL CENTER

Table of content: MISS KATRINA MICHELLE AMEZCUA APCC (NPI 1952919979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871936716 NPI number — FOREVER YOUTHFUL ADULT EDUCATIONAL AND RECREATIONAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOREVER YOUTHFUL ADULT EDUCATIONAL AND RECREATIONAL CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FOREVER YOUTHFUL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871936716
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
149 EAST PEELER AVENUE
Provider Second Line Business Mailing Address:
PO BOX 1053
Provider Business Mailing Address City Name:
SHAW
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38733-1053
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-754-3114
Provider Business Mailing Address Fax Number:
662-754-3055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
149 EAST PEELER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHAW
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38733-1053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-754-3114
Provider Business Practice Location Address Fax Number:
662-754-3055
Provider Enumeration Date:
04/10/2013

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
MILDRED
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
662-754-3114

Provider Taxonomy Codes

  • Taxonomy code: 261QA0600X , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com