Provider Demographics
NPI:1649527284
Name:FOUNTAIN OF YOUTH MD LLC
Entity type:Organization
Organization Name:FOUNTAIN OF YOUTH MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OFFER
Authorized Official - Middle Name:
Authorized Official - Last Name:DANAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-695-5500
Mailing Address - Street 1:200 GALLERIA PKWY SE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-5918
Mailing Address - Country:US
Mailing Address - Phone:770-695-5500
Mailing Address - Fax:800-814-3301
Practice Address - Street 1:200 GALLERIA PKWY SE
Practice Address - Street 2:SUITE 100
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-5918
Practice Address - Country:US
Practice Address - Phone:770-695-5500
Practice Address - Fax:800-814-3301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-14
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty