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General NPI Number Information
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NPI Number | 1619661238
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Entity Type | Organization
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Legal Business Name | FOUNTAIN OF YOUTH COMMUNITY SERVICES LLC
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Dates
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Enumeration Date | 06/06/2023
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Last Update Date | 06/06/2023
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Provider Practice Location Address
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Address Line | 3618 CHASE CT
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City | VA BEACH
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State | VA
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Zip | 23462-6805
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Country | US
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Telephone | 757-305-6887
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Fax |
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Provider Business Mailing Address
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Address Line | 3793 FIELDSTONE CIR
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City | VIRGINIA BEACH
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State | VA
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Zip | 23453-4713
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. DREQUEZ LAMBERT
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Credential |
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Telephone | 757-305-6887
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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