Provider Demographics
NPI:1710223573
Name:FOUNTAIN OF LIFE LLC
Entity Type:Organization
Organization Name:FOUNTAIN OF LIFE LLC
Other - Org Name:MEDCUBA CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DR
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-548-1701
Mailing Address - Street 1:1820 W 43RD ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77018-3006
Mailing Address - Country:US
Mailing Address - Phone:832-548-1701
Mailing Address - Fax:713-393-7466
Practice Address - Street 1:1820 W 43RD ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77018-3006
Practice Address - Country:US
Practice Address - Phone:832-548-1701
Practice Address - Fax:713-393-7466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-26
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care