Provider Demographics
NPI:1326753591
Name:FOUNTAIN OF PEACE LLC
Entity Type:Organization
Organization Name:FOUNTAIN OF PEACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:YANICK
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:CAMILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-401-0074
Mailing Address - Street 1:875 CALICO SCALLOP ST
Mailing Address - Street 2:
Mailing Address - City:RUSKIN
Mailing Address - State:FL
Mailing Address - Zip Code:33570-8099
Mailing Address - Country:US
Mailing Address - Phone:813-401-0074
Mailing Address - Fax:
Practice Address - Street 1:3060 E COLLEGE AVE # 1009
Practice Address - Street 2:
Practice Address - City:RUSKIN
Practice Address - State:FL
Practice Address - Zip Code:33570-5220
Practice Address - Country:US
Practice Address - Phone:813-401-0074
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOUNTAIN OF PEACE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-01-20
Last Update Date:2023-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health