Provider Demographics
NPI:1073873915
Name:FOUNTAIN HOPE AND HEALTH FOR YOUTH
Entity Type:Organization
Organization Name:FOUNTAIN HOPE AND HEALTH FOR YOUTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ABRAHAM
Authorized Official - Middle Name:WALE
Authorized Official - Last Name:JIMOH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-755-5632
Mailing Address - Street 1:2930 W IMPERIAL HWY
Mailing Address - Street 2:510
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90303-3143
Mailing Address - Country:US
Mailing Address - Phone:323-755-5632
Mailing Address - Fax:323-755-5630
Practice Address - Street 1:2930 W IMPERIAL HWY
Practice Address - Street 2:510
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90303-3143
Practice Address - Country:US
Practice Address - Phone:323-755-5632
Practice Address - Fax:323-755-5630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-25
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0000000000OtherMEDI-CAL