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NPI Code Detail

MEDICARE: ELEVENTH HOURS FOUNTAIN OF YOUTH LLC

MEDICARE: ELEVENTH HOURS FOUNTAIN OF YOUTH LLC
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
1261QM0801XMental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number : 1811693203
Entity Type Code : Organization
Provider Name (Legal Business Name) : ELEVENTH HOURS FOUNTAIN OF YOUTH LLC
Provider Business Mailing Address
First Line : 1254 E 24TH ST
Second Line :
City : TUCSON
State : AZ
Zip : 85713-1846
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1025 E SILVERLAKE RD
Second Line :
City : TUCSON
State : AZ
Zip : 85713-3227
Country : US
Telephone Number : 480-869-5550
Fax Number :
Authorized Official
Title or Position : OWNER
Name : BRITTANY C LYLES
Credential :
Telephone Number : 480-869-5550
Provider Enumeration Date : 02/07/2023
Last Update Date : 02/07/2023

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Directions to “ELEVENTH HOURS FOUNTAIN OF YOUTH LLC ” Practice Location

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These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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