MEDICARE: FOUNTAIN OF LIFE LLC

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1710223573
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOUNTAIN OF LIFE LLC

Provider Business Mailing Address
First Line	:	1820 W 43RD ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77018-3006
Country	:	US
Telephone Number	:	832-548-1701
Fax Number	:	713-393-7466

Provider Business Practice Location Address
First Line	:	1820 W 43RD ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77018-3006
Country	:	US
Telephone Number	:	832-548-1701
Fax Number	:	713-393-7466

Authorized Official
Title or Position	:	DR
Name	:	MS. CYNTHIA DIANE GOODMAN
Credential	:
Telephone Number	:	832-548-1701

Provider Enumeration Date	:	12/26/2012
Last Update Date	:	07/30/2013

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Directions to “FOUNTAIN OF LIFE LLC ” Practice Location

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