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General NPI Number Information
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NPI Number | 1558672329
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Entity Type | Organization
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Legal Business Name | FOUNTAIN OF LIFE WELLNESS CENTER
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Dates
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Enumeration Date | 06/27/2010
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Last Update Date | 06/27/2010
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Provider Practice Location Address
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Address Line | 1314 72ND ST E
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City | TACOMA
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State | WA
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Zip | 98404-3343
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Country | US
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Telephone | 253-380-5263
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Fax |
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Provider Business Mailing Address
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Address Line | 14010 68TH AVE E
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City | PUYALLUP
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State | WA
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Zip | 98373-8706
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Country | US
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Telephone | 253-380-5263
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | BRENDA MILEWSKI
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Credential |
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Telephone | 253-380-5263
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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 | 602786502
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License Number State | WA
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