Provider Demographics
NPI:1629649272
Name:FOUNTAIN OF LIFE GROUP HOMES LLC
Entity Type:Organization
Organization Name:FOUNTAIN OF LIFE GROUP HOMES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-459-0913
Mailing Address - Street 1:7436 ROSE CREST BLVD.
Mailing Address - Street 2:
Mailing Address - City:FOREST HILL
Mailing Address - State:TX
Mailing Address - Zip Code:76140
Mailing Address - Country:US
Mailing Address - Phone:317-469-0913
Mailing Address - Fax:
Practice Address - Street 1:7436 ROSE CREST BLVD.
Practice Address - Street 2:
Practice Address - City:FOREST HILL
Practice Address - State:TX
Practice Address - Zip Code:76140
Practice Address - Country:US
Practice Address - Phone:317-469-0913
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities