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General NPI Number Information
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NPI Number | 1225202179
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Entity Type | Organization
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Legal Business Name | FOUNTAIN OF YOUTH, INC
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Dates
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Enumeration Date | 04/22/2008
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Last Update Date | 09/05/2012
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Provider Practice Location Address
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Address Line | 2409 S 56TH ST SUITE 121
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City | FORT SMITH
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State | AR
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Zip | 72903-3753
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Country | US
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Telephone | 479-484-7782
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Fax | 479-484-7951
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Provider Business Mailing Address
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Address Line | 2409 S 56TH ST SUITE 121
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City | FORT SMITH
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State | AR
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Zip | 72903-3753
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Country | US
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Telephone | 479-484-7782
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Fax | 479-484-7951
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Authorized Official
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Title or Position | SITE DIRECTOR
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Name | MICHELLE FOUTCH
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Credential |
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Telephone | 479-484-7782
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251V00000X
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Taxonomy Name | Voluntary or Charitable Agency
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License Number | 105
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License Number State | AR
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