Provider Demographics
NPI:1134797715
Name:FOUNTAIN OF YOUTH ACTIVITY CENTER, LLC
Entity type:Organization
Organization Name:FOUNTAIN OF YOUTH ACTIVITY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-503-9865
Mailing Address - Street 1:8801 E 63RD ST STE 101
Mailing Address - Street 2:
Mailing Address - City:RAYTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:64133-4865
Mailing Address - Country:US
Mailing Address - Phone:816-503-9865
Mailing Address - Fax:
Practice Address - Street 1:8801 E 63RD ST STE 101
Practice Address - Street 2:
Practice Address - City:RAYTOWN
Practice Address - State:MO
Practice Address - Zip Code:64133-4865
Practice Address - Country:US
Practice Address - Phone:816-886-0442
Practice Address - Fax:816-503-9408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)