Provider Demographics
NPI:1659076875
Name:FOUNTAIN OF HOPE HOME CARE SERVICES LLC
Entity Type:Organization
Organization Name:FOUNTAIN OF HOPE HOME CARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:MMBAKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-658-8440
Mailing Address - Street 1:6008 BRANDY CHASE CV STE B
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-7601
Mailing Address - Country:US
Mailing Address - Phone:317-658-8440
Mailing Address - Fax:
Practice Address - Street 1:6008 BRANDY CHASE CV STE B
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-7601
Practice Address - Country:US
Practice Address - Phone:317-658-8440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-05
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care