Provider Demographics
NPI:1104194356
Name:FOUNTAIN OF LIFE COMMUNITY DEVELOPMENT CENTER
Entity Type:Organization
Organization Name:FOUNTAIN OF LIFE COMMUNITY DEVELOPMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHERRON
Authorized Official - Middle Name:
Authorized Official - Last Name:PARRISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-391-6080
Mailing Address - Street 1:6741 PEMBROKE RD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33023-2143
Mailing Address - Country:US
Mailing Address - Phone:954-391-6080
Mailing Address - Fax:954-391-6081
Practice Address - Street 1:6741 PEMBROKE RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33023-2143
Practice Address - Country:US
Practice Address - Phone:954-391-6080
Practice Address - Fax:954-391-6081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-02
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health