Organization Name: | FOUNTAIN OF YOUTH, LLC |
NPI Number: | 1316205115 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | SHERRI JERNBERG (OWNER/OPERATOR) |
Mailing Address: | 8810 Wabash Ave Terre Haute |
State: | IN US |
Postal Code: | 478033908 |
Phone Number: | 8122394090 |
Fax Number: | |
NPI Enumeration Date: | 04/30/2012 |
NPI Last Update Date: | 04/30/2012 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 261Q00000X |
License Number: | 71002624A |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | IN |
Taxonomy Type: | Ambulatory Health Care Facilities |
Taxonomy Classification: | Clinic/Center |
Taxonomy Specialization: | |
Taxonomy Definition: | A facility or distinct part of one used for the diagnosis and treatment of outpatients. "Clinic/Center" is irregularly defined, sometimes being limited to organizations serving specialized treatment requirements or distinct patient/client groups (e.g., radiology, poor, and public health). |