MEDICARE: FOUNTAIN OF LOVE ASSISTED LIVING SEVICES INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	343900000X	Non-emergency Medical Transport (VAN)
2	261QA0600X	Adult Day Care Clinic/Center

General Provider Information

NPI Number	:	1497160477
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOUNTAIN OF LOVE ASSISTED LIVING SEVICES INC

Provider Business Mailing Address
First Line	:	21820 BEVERLY ST
Second Line	:
City	:	OAK PARK
State	:	MI
Zip	:	48237-2503
Country	:	US
Telephone Number	:	248-796-7112
Fax Number	:	248-808-6052

Provider Business Practice Location Address
First Line	:	21820 BEVERLY ST
Second Line	:
City	:	OAK PARK
State	:	MI
Zip	:	48237-2503
Country	:	US
Telephone Number	:	248-796-7112
Fax Number	:	248-808-6052

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SHANELL CLARK
Credential	:
Telephone Number	:	248-796-8004

Provider Enumeration Date	:	06/27/2014
Last Update Date	:	04/21/2016

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