Provider Demographics
NPI:1417560269
Name:FOUNTAIN OF LOVE
Entity Type:Organization
Organization Name:FOUNTAIN OF LOVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH CARE WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-543-4480
Mailing Address - Street 1:307 MANDY ROSE TRCE
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-2353
Mailing Address - Country:US
Mailing Address - Phone:313-543-4480
Mailing Address - Fax:
Practice Address - Street 1:2140 DICKERSON ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48215-2640
Practice Address - Country:US
Practice Address - Phone:313-543-4480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GLOBAL PRECISION INVESTMENT GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-08-30
Last Update Date:2020-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency