Provider Demographics
NPI:1700474632
Name:FOUNTAIN OF LIFE HOSPICE
Entity Type:Organization
Organization Name:FOUNTAIN OF LIFE HOSPICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ARCHIBON
Authorized Official - Middle Name:
Authorized Official - Last Name:LAMARIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-267-7495
Mailing Address - Street 1:818 N MOUNTAIN AVE STE 203B
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4165
Mailing Address - Country:US
Mailing Address - Phone:951-267-7495
Mailing Address - Fax:951-267-7689
Practice Address - Street 1:818 N MOUNTAIN AVE STE 203B
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4165
Practice Address - Country:US
Practice Address - Phone:951-267-7495
Practice Address - Fax:951-267-7689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based