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General NPI Number Information
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NPI Number | 1558669671
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Entity Type | Organization
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Legal Business Name | FOUNTAIN OF LIFE HOUSING
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Dates
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Enumeration Date | 03/14/2011
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Last Update Date | 03/14/2011
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Provider Practice Location Address
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Address Line | 2319 PANNELL ST
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City | HOUSTON
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State | TX
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Zip | 77026-6536
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Country | US
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Telephone | 713-320-2772
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Fax |
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Provider Business Mailing Address
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Address Line | 2319 PANNELL ST
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City | HOUSTON
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State | TX
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Zip | 77026-6536
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Country | US
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Telephone | 713-320-2772
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MR. CARL DEAN BROWN
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Credential |
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Telephone | 713-320-2772
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number |
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License Number State |
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