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General NPI Number Information
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NPI Number | 1528673738
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Entity Type | Organization
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Legal Business Name | FOUNTAIN OF LIFE HOME HEALTHCARE
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Dates
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Enumeration Date | 09/14/2020
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Last Update Date | 09/14/2020
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Provider Practice Location Address
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Address Line | 11414 W PARK PL STE 202
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City | MILWAUKEE
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State | WI
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Zip | 53224-3500
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Country | US
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Telephone | 414-716-6146
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Fax | 414-509-1635
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Provider Business Mailing Address
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Address Line | 11414 W PARK PL STE 202
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City | MILWAUKEE
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State | WI
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Zip | 53224-3500
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Country | US
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Telephone | 414-716-6146
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Fax | 414-509-1635
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Authorized Official
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Title or Position | OWNER
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Name | MR. GREGORY STEVENSON
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Credential |
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Telephone | 414-716-6146
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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