Provider Demographics
NPI:1598190506
Name:THE YOUTH FOUNTAIN
Entity Type:Organization
Organization Name:THE YOUTH FOUNTAIN
Other - Org Name:YOUTH FOUNTAIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EMIL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAKOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:866-514-0025
Mailing Address - Street 1:501 IRON BRIDGE RD
Mailing Address - Street 2:SUITE 9
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-5304
Mailing Address - Country:US
Mailing Address - Phone:866-514-0025
Mailing Address - Fax:732-358-0524
Practice Address - Street 1:501 IRON BRIDGE RD
Practice Address - Street 2:SUITE 9
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-5304
Practice Address - Country:US
Practice Address - Phone:866-514-0025
Practice Address - Fax:732-358-0524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-09
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty