Provider Demographics
NPI:1598338360
Name:FOUNTAIN OF HOPE LLC
Entity Type:Organization
Organization Name:FOUNTAIN OF HOPE LLC
Other - Org Name:FOUNTAIN OF HOPE PERSONAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHYNDONA
Authorized Official - Middle Name:LYNETTE
Authorized Official - Last Name:DICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-604-2448
Mailing Address - Street 1:2300 W SAHARA AVE STE 800
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-4397
Mailing Address - Country:US
Mailing Address - Phone:702-604-2448
Mailing Address - Fax:725-605-5874
Practice Address - Street 1:2300 W SAHARA AVE STE 800
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-4397
Practice Address - Country:US
Practice Address - Phone:702-604-2448
Practice Address - Fax:725-605-5874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-20
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV10472-PCS-1OtherDEPARTMENT PUBLIC BEHAVIOR HEALTH
NV505TW76717OtherMEDICARE TRI WEST
NV250017446Medicaid