Provider Demographics
NPI:1134947591
Name:A FOUNTAIN OF YOUTH HOME CARE LLC
Entity type:Organization
Organization Name:A FOUNTAIN OF YOUTH HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHANTELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-820-8328
Mailing Address - Street 1:2229 RICHWOOD PIKE DR
Mailing Address - Street 2:
Mailing Address - City:RUSKIN
Mailing Address - State:FL
Mailing Address - Zip Code:33570-8003
Mailing Address - Country:US
Mailing Address - Phone:813-820-8328
Mailing Address - Fax:
Practice Address - Street 1:2229 RICHWOOD PIKE DR
Practice Address - Street 2:
Practice Address - City:RUSKIN
Practice Address - State:FL
Practice Address - Zip Code:33570-8003
Practice Address - Country:US
Practice Address - Phone:813-820-8328
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services