Provider Demographics
NPI:1932820925
Name:FOUNTAIN OF YOUTH ACUPUNCTURE LLC
Entity Type:Organization
Organization Name:FOUNTAIN OF YOUTH ACUPUNCTURE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELINA
Authorized Official - Middle Name:
Authorized Official - Last Name:KRAUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-741-6802
Mailing Address - Street 1:1083 GENNETT CIR APT 209
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-6243
Mailing Address - Country:US
Mailing Address - Phone:201-741-6802
Mailing Address - Fax:
Practice Address - Street 1:1474 SC-160
Practice Address - Street 2:SUITE 103
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715
Practice Address - Country:US
Practice Address - Phone:201-741-6802
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty