Healthcare Provider Details

I. General information

NPI: 1225202179
Provider Name (Legal Business Name): FOUNTAIN OF YOUTH, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 09/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2409 S 56TH ST SUITE 121
FORT SMITH AR
72903-3753
US

IV. Provider business mailing address

2409 S 56TH ST SUITE 121
FORT SMITH AR
72903-3753
US

V. Phone/Fax

Practice location:
  • Phone: 479-484-7782
  • Fax: 479-484-7951
Mailing address:
  • Phone: 479-484-7782
  • Fax: 479-484-7951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number105
License Number StateAR

VIII. Authorized Official

Name: MICHELLE FOUTCH
Title or Position: SITE DIRECTOR
Credential:
Phone: 479-484-7782