Healthcare Provider Details

I. General information

NPI: 1174336937
Provider Name (Legal Business Name): FOUNTAIN OF LOVE HOME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2025
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4371 LAKE PRINCE DR
SUFFOLK VA
23434-6822
US

IV. Provider business mailing address

4371 LAKE PRINCE DR
SUFFOLK VA
23434-6822
US

V. Phone/Fax

Practice location:
  • Phone: 757-633-5245
  • Fax:
Mailing address:
  • Phone: 757-633-5245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: TYISHA MICHELLE BASKERVILLE
Title or Position: CEO
Credential:
Phone: 757-633-5245