Provider Demographics
NPI:1619661238
Name:FOUNTAIN OF YOUTH COMMUNITY SERVICES LLC
Entity Type:Organization
Organization Name:FOUNTAIN OF YOUTH COMMUNITY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DREQUEZ
Authorized Official - Middle Name:
Authorized Official - Last Name:LAMBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-305-6887
Mailing Address - Street 1:3793 FIELDSTONE CIR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23453-4713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3618 CHASE CT
Practice Address - Street 2:
Practice Address - City:VA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-6805
Practice Address - Country:US
Practice Address - Phone:757-305-6887
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care