Provider Demographics
NPI:1689912511
Name:FOUNTAIN OF LIFE HOME HEALTH CARE LLC
Entity Type:Organization
Organization Name:FOUNTAIN OF LIFE HOME HEALTH CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-363-9095
Mailing Address - Street 1:8500 AUBURN DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76123-1732
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8500 AUBURN DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76123-1732
Practice Address - Country:US
Practice Address - Phone:317-363-9095
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-28
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health