Organization Name: | FOUNTAIN OF YOUTH MD LLC |
NPI Number: | 1649527284 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | OFFER DANAN (OWNER) |
Mailing Address: | 200 Galleria Pkwy Se Suite 100 Atlanta |
State: | GA US |
Postal Code: | 303395918 |
Phone Number: | 7706955500 |
Fax Number: | 8008143301 |
NPI Enumeration Date: | 08/14/2012 |
NPI Last Update Date: | 05/22/2014 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 208D00000X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Allopathic & Osteopathic Physicians |
Taxonomy Classification: | General Practice |
Taxonomy Specialization: | |
Taxonomy Definition: |