MEDICARE: FOUNTAIN OF LIFE HEALTHCARE PC.

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1396494878
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOUNTAIN OF LIFE HEALTHCARE PC.

Provider Business Mailing Address
First Line	:	7375 EXECUTIVE PL
Second Line	:
City	:	LANHAM
State	:	MD
Zip	:	20706-2278
Country	:	US
Telephone Number	:	301-806-7473
Fax Number	:	410-988-2868

Provider Business Practice Location Address
First Line	:	7375 EXECUTIVE PL
Second Line	:
City	:	LANHAM
State	:	MD
Zip	:	20706-2278
Country	:	US
Telephone Number	:	301-806-7473
Fax Number	:	410-988-2868

Authorized Official
Title or Position	:	PROVIDER
Name	:	CHIDI ROOVELT NWACHUKWU
Credential	:
Telephone Number	:	410-777-5292

Provider Enumeration Date	:	03/22/2022
Last Update Date	:	07/13/2023

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