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General NPI Number Information
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NPI Number | 1417560269
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Entity Type | Organization
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Legal Business Name | FOUNTAIN OF LOVE
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Dates
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Enumeration Date | 08/30/2020
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Last Update Date | 08/30/2020
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Provider Practice Location Address
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Address Line | 2140 DICKERSON ST
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City | DETROIT
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State | MI
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Zip | 48215-2640
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Country | US
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Telephone | 313-543-4480
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Fax |
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Provider Business Mailing Address
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Address Line | 307 MANDY ROSE TRCE
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City | STOCKBRIDGE
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State | GA
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Zip | 30281-2353
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Country | US
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Telephone | 313-543-4480
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Fax |
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Authorized Official
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Title or Position | HEALTH CARE WORKER
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Name | MS. TAMIKA BURNETTE
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Credential |
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Telephone | 313-543-4480
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253J00000X
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Taxonomy Name | Foster Care Agency
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License Number |
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License Number State |
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