Provider Demographics
NPI:1093598633
Name:FOUNTAIN OF YOUTH ADULT DAY CENTER
Entity Type:Organization
Organization Name:FOUNTAIN OF YOUTH ADULT DAY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JASMEKA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-970-9475
Mailing Address - Street 1:54 W 153RD PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-1007
Mailing Address - Country:US
Mailing Address - Phone:708-970-9475
Mailing Address - Fax:
Practice Address - Street 1:700 SIBLEY ST
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46320-1635
Practice Address - Country:US
Practice Address - Phone:708-970-9475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-16
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care