Provider Demographics
NPI:1336829514
Name:FOUNTAIN LIFE DALLAS, LLC
Entity Type:Organization
Organization Name:FOUNTAIN LIFE DALLAS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLINICAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-810-8672
Mailing Address - Street 1:5762 GRANDSCAPE BLVD STE 115
Mailing Address - Street 2:
Mailing Address - City:THE COLONY
Mailing Address - State:TX
Mailing Address - Zip Code:75056-6782
Mailing Address - Country:US
Mailing Address - Phone:469-669-0336
Mailing Address - Fax:
Practice Address - Street 1:5762 GRANDSCAPE BLVD STE 115
Practice Address - Street 2:
Practice Address - City:THE COLONY
Practice Address - State:TX
Practice Address - Zip Code:75056-6782
Practice Address - Country:US
Practice Address - Phone:469-669-0336
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-21
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center