Healthcare Provider Details

I. General information

NPI: 1134797715
Provider Name (Legal Business Name): FOUNTAIN OF YOUTH ACTIVITY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2021
Last Update Date: 06/11/2021
Certification Date: 06/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8801 E 63RD ST STE 101
RAYTOWN MO
64133-4865
US

IV. Provider business mailing address

8801 E 63RD ST STE 101
RAYTOWN MO
64133-4865
US

V. Phone/Fax

Practice location:
  • Phone: 816-886-0442
  • Fax: 816-503-9408
Mailing address:
  • Phone: 816-503-9865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: JOHN PARKER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 816-503-9865