Provider Demographics
NPI:1396494878
Name:FOUNTAIN OF LIFE HEALTHCARE PC.
Entity type:Organization
Organization Name:FOUNTAIN OF LIFE HEALTHCARE PC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:CHIDI
Authorized Official - Middle Name:ROOVELT
Authorized Official - Last Name:NWACHUKWU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-777-5292
Mailing Address - Street 1:7375 EXECUTIVE PL
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-2278
Mailing Address - Country:US
Mailing Address - Phone:301-806-7473
Mailing Address - Fax:410-988-2868
Practice Address - Street 1:7375 EXECUTIVE PL
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-2278
Practice Address - Country:US
Practice Address - Phone:301-806-7473
Practice Address - Fax:410-988-2868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-22
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty