Provider Demographics
NPI:1568884427
Name:FOUNTAIN OF YOUTH LLC
Entity Type:Organization
Organization Name:FOUNTAIN OF YOUTH LLC
Other - Org Name:CARE GIVERS SOLUTIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-755-8324
Mailing Address - Street 1:120 CENTER PARK DR
Mailing Address - Street 2:SUITE 9
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-2117
Mailing Address - Country:US
Mailing Address - Phone:865-755-8324
Mailing Address - Fax:
Practice Address - Street 1:120 CENTER PARK DR
Practice Address - Street 2:SUITE 9
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-2117
Practice Address - Country:US
Practice Address - Phone:865-755-8324
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-13
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1000000013818253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care