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General NPI Number Information
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NPI Number | 1104194356
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Entity Type | Organization
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Legal Business Name | FOUNTAIN OF LIFE COMMUNITY DEVELOPMENT CENTER
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Dates
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Enumeration Date | 12/02/2011
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Last Update Date | 12/02/2011
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Provider Practice Location Address
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Address Line | 6741 PEMBROKE RD
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City | PEMBROKE PINES
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State | FL
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Zip | 33023-2143
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Country | US
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Telephone | 954-391-6080
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Fax | 954-391-6081
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Provider Business Mailing Address
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Address Line | 6741 PEMBROKE RD
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City | PEMBROKE PINES
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State | FL
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Zip | 33023-2143
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Country | US
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Telephone | 954-391-6080
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Fax | 954-391-6081
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Authorized Official
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Title or Position | CEO
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Name | SHERRON PARRISH
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Credential |
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Telephone | 954-391-6080
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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