Healthcare Provider Details

I. General information

NPI: 1144630963
Provider Name (Legal Business Name): FOUNTAIN OF YOUTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2014
Last Update Date: 05/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 DUMONT AVE
STATEN ISLAND NY
10305-1450
US

IV. Provider business mailing address

26 DUMONT AVE
STATEN ISLAND NY
10305-1450
US

V. Phone/Fax

Practice location:
  • Phone: 718-667-8510
  • Fax: 718-667-8884
Mailing address:
  • Phone: 718-667-8510
  • Fax: 718-667-8884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRENT ALEXANDER
Title or Position: PRESIDENT
Credential:
Phone: 718-667-8521