Provider Demographics
NPI:1093021859
Name:FOUNTAIN OF LOVE ASSISTED LIVING INC
Entity Type:Organization
Organization Name:FOUNTAIN OF LOVE ASSISTED LIVING INC
Other - Org Name:THE LOVING HEAD QUARTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHANELL
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-796-7291
Mailing Address - Street 1:21820 BEVERLY ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-2503
Mailing Address - Country:US
Mailing Address - Phone:248-796-7291
Mailing Address - Fax:
Practice Address - Street 1:21820 BEVERLY ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-2503
Practice Address - Country:US
Practice Address - Phone:248-796-7291
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-30
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X, 311ZA0620X, 320800000X, 385H00000X
MIAF630309030310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No385H00000XRespite Care FacilityRespite CareGroup - Multi-Specialty