Healthcare Provider Details

I. General information

NPI: 1598338360
Provider Name (Legal Business Name): FOUNTAIN OF HOPE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 W SAHARA AVE STE 800
LAS VEGAS NV
89102-4397
US

IV. Provider business mailing address

2300 W SAHARA AVE STE 800
LAS VEGAS NV
89102-4397
US

V. Phone/Fax

Practice location:
  • Phone: 702-604-2448
  • Fax: 725-605-5874
Mailing address:
  • Phone: 702-604-2448
  • Fax: 725-605-5874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. SHYNDONA LYNETTE DICKERSON
Title or Position: ADMINISTRATOR
Credential:
Phone: 702-604-2448