Provider Demographics
NPI:1376755140
Name:FUENTE DE JUVENTUD, INC.
Entity Type:Organization
Organization Name:FUENTE DE JUVENTUD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:SONIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLEGOS
Authorized Official - Suffix:
Authorized Official - Credentials:BS MPH
Authorized Official - Phone:956-702-3323
Mailing Address - Street 1:1138 E EXPRESSWAY 83
Mailing Address - Street 2:SUITE E
Mailing Address - City:PHARR
Mailing Address - State:TX
Mailing Address - Zip Code:78577-6518
Mailing Address - Country:US
Mailing Address - Phone:956-702-3323
Mailing Address - Fax:956-702-3324
Practice Address - Street 1:1138 E EXPRESSWAY 83
Practice Address - Street 2:SUITE E
Practice Address - City:PHARR
Practice Address - State:TX
Practice Address - Zip Code:78577-6518
Practice Address - Country:US
Practice Address - Phone:956-702-3323
Practice Address - Fax:956-702-3324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care