Provider Demographics
NPI:1225202179
Name:FOUNTAIN OF YOUTH, INC
Entity Type:Organization
Organization Name:FOUNTAIN OF YOUTH, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SITE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:FOUTCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-484-7782
Mailing Address - Street 1:2409 S 56TH ST
Mailing Address - Street 2:SUITE 121
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-3753
Mailing Address - Country:US
Mailing Address - Phone:479-484-7782
Mailing Address - Fax:479-484-7951
Practice Address - Street 1:2409 S 56TH ST
Practice Address - Street 2:SUITE 121
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-3753
Practice Address - Country:US
Practice Address - Phone:479-484-7782
Practice Address - Fax:479-484-7951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR105251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR165464755Medicaid