Provider Demographics
NPI:1083491344
Name:FOUNT OF LIFE LLC
Entity Type:Organization
Organization Name:FOUNT OF LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARQUIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-661-5505
Mailing Address - Street 1:225 MARKET PLACE CONNECTOR # 1143
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-3542
Mailing Address - Country:US
Mailing Address - Phone:888-260-4205
Mailing Address - Fax:
Practice Address - Street 1:580 CALEDON WAY
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228
Practice Address - Country:US
Practice Address - Phone:888-260-4205
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Single Specialty
No376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty