MEDICARE: FOUNTAIN OF YOUTH, 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	251V00000X	Voluntary or Charitable Agency	105	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225202179
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOUNTAIN OF YOUTH, INC

Provider Business Mailing Address
First Line	:	2409 S 56TH ST
Second Line	:	SUITE 121
City	:	FORT SMITH
State	:	AR
Zip	:	72903-3753
Country	:	US
Telephone Number	:	479-484-7782
Fax Number	:	479-484-7951

Provider Business Practice Location Address
First Line	:	2409 S 56TH ST
Second Line	:	SUITE 121
City	:	FORT SMITH
State	:	AR
Zip	:	72903-3753
Country	:	US
Telephone Number	:	479-484-7782
Fax Number	:	479-484-7951

Authorized Official
Title or Position	:	SITE DIRECTOR
Name	:	MICHELLE FOUTCH
Credential	:
Telephone Number	:	479-484-7782

Provider Enumeration Date	:	04/22/2008
Last Update Date	:	09/05/2012

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