Provider Demographics
NPI:1740042605
Name:FLOURISH FOUNDATION
Entity type:Organization
Organization Name:FLOURISH FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:JONTA
Authorized Official - Middle Name:DELISA
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-286-8603
Mailing Address - Street 1:172 WATER OAK WAY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-8562
Mailing Address - Country:US
Mailing Address - Phone:480-286-8603
Mailing Address - Fax:
Practice Address - Street 1:172 WATER OAK WAY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-8562
Practice Address - Country:US
Practice Address - Phone:480-286-8603
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-26
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251E00000XAgenciesHome Health