Provider Demographics
NPI:1952693988
Name:FOUNTAIN OF CARE, LLC
Entity Type:Organization
Organization Name:FOUNTAIN OF CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:N
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-969-5128
Mailing Address - Street 1:29225 HERITAGE CT
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-1743
Mailing Address - Country:US
Mailing Address - Phone:313-969-5128
Mailing Address - Fax:248-785-3623
Practice Address - Street 1:29225 HERITAGE CT
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-1743
Practice Address - Country:US
Practice Address - Phone:313-969-5128
Practice Address - Fax:248-785-3623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-10
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care