Healthcare Provider Details

I. General information

NPI: 1386119683
Provider Name (Legal Business Name): FOUNTAIN OF HOPE L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2018
Last Update Date: 06/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

268 DELTA WATERS ST
HENDERSON NV
89074-8712
US

IV. Provider business mailing address

268 DELTA WATERS ST
HENDERSON NV
89074-8712
US

V. Phone/Fax

Practice location:
  • Phone: 725-400-4098
  • Fax: 725-605-5874
Mailing address:
  • Phone: 725-400-4098
  • Fax: 725-605-5874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: SHYNDONA YOUNG
Title or Position: CEO
Credential:
Phone: 725-400-4098