MEDICARE: FOUNTAIN OF LOVE ASSISTED LIVING INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	AF630309030	MI
2	311ZA0620X	Adult Care Home Facility
3	320800000X	Mental Illness Community Based Residential Treatment Facility
4	385H00000X	Respite Care
5	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1093021859
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOUNTAIN OF LOVE ASSISTED LIVING INC

Provider Business Mailing Address
First Line	:	21820 BEVERLY ST
Second Line	:
City	:	OAK PARK
State	:	MI
Zip	:	48237-2503
Country	:	US
Telephone Number	:	248-796-7291
Fax Number	:

Provider Business Practice Location Address
First Line	:	21820 BEVERLY ST
Second Line	:
City	:	OAK PARK
State	:	MI
Zip	:	48237-2503
Country	:	US
Telephone Number	:	248-796-7291
Fax Number	:

Authorized Official
Title or Position	:	OFFICER
Name	:	MS. SHANELL CLARK
Credential	:
Telephone Number	:	248-796-7291

Provider Enumeration Date	:	08/30/2010
Last Update Date	:	11/15/2018

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