Provider Demographics
NPI:1497160477
Name:FOUNTAIN OF LOVE ASSISTED LIVING SEVICES INC
Entity Type:Organization
Organization Name:FOUNTAIN OF LOVE ASSISTED LIVING SEVICES INC
Other - Org Name:4-WINGS TRANSPORTATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHANELL
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-796-8004
Mailing Address - Street 1:21820 BEVERLY ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-2503
Mailing Address - Country:US
Mailing Address - Phone:248-796-7112
Mailing Address - Fax:248-808-6052
Practice Address - Street 1:21820 BEVERLY ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-2503
Practice Address - Country:US
Practice Address - Phone:248-796-7112
Practice Address - Fax:248-808-6052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-27
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)