Healthcare Provider Details

I. General information

NPI: 1306583117
Provider Name (Legal Business Name): FUENTE DE JUVENTUD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2022
Last Update Date: 05/14/2022
Certification Date: 05/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2008 REDSKIN AVE STE A
DONNA TX
78537-3299
US

IV. Provider business mailing address

1138 E INTERSTATE 2 STE E
PHARR TX
78577-6519
US

V. Phone/Fax

Practice location:
  • Phone: 956-377-5158
  • Fax: 956-377-5204
Mailing address:
  • Phone: 956-702-3323
  • Fax: 956-782-5448

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: SONIA GALLEGOS
Title or Position: ADMINISTRATOR
Credential: MPH
Phone: 956-702-3323