Healthcare Provider Details

I. General information

NPI: 1093021859
Provider Name (Legal Business Name): FOUNTAIN OF LOVE ASSISTED LIVING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2010
Last Update Date: 11/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21820 BEVERLY ST
OAK PARK MI
48237-2503
US

IV. Provider business mailing address

21820 BEVERLY ST
OAK PARK MI
48237-2503
US

V. Phone/Fax

Practice location:
  • Phone: 248-796-7291
  • Fax:
Mailing address:
  • Phone: 248-796-7291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAF630309030
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: MS. SHANELL CLARK
Title or Position: OFFICER
Credential:
Phone: 248-796-7291