MEDICARE: FOUNTAIN OF LIFE WELLNESS CENTER

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	602786502	WA

General Provider Information

NPI Number	:	1558672329
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOUNTAIN OF LIFE WELLNESS CENTER

Provider Business Mailing Address
First Line	:	14010 68TH AVE E
Second Line	:
City	:	PUYALLUP
State	:	WA
Zip	:	98373-8706
Country	:	US
Telephone Number	:	253-380-5263
Fax Number	:

Provider Business Practice Location Address
First Line	:	1314 72ND ST E
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98404-3343
Country	:	US
Telephone Number	:	253-380-5263
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	BRENDA MILEWSKI
Credential	:
Telephone Number	:	253-380-5263

Provider Enumeration Date	:	06/27/2010
Last Update Date	:	06/27/2010

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Directions to “FOUNTAIN OF LIFE WELLNESS CENTER ” Practice Location

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