Healthcare Provider Details

I. General information

NPI: 1952693988
Provider Name (Legal Business Name): FOUNTAIN OF CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2011
Last Update Date: 09/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29225 HERITAGE CT
SOUTHFIELD MI
48076-1743
US

IV. Provider business mailing address

29225 HERITAGE CT
SOUTHFIELD MI
48076-1743
US

V. Phone/Fax

Practice location:
  • Phone: 313-969-5128
  • Fax: 248-785-3623
Mailing address:
  • Phone: 313-969-5128
  • Fax: 248-785-3623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. LORI N CLARK
Title or Position: OWNER/ADMINISTRATOR
Credential:
Phone: 313-969-5128