Provider Demographics
NPI:1306608195
Name:FOUNTAIN OF YOUTH LLC RESIDENTIAL CARE
Entity type:Organization
Organization Name:FOUNTAIN OF YOUTH LLC RESIDENTIAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTER
Authorized Official - Prefix:
Authorized Official - First Name:SADIO
Authorized Official - Middle Name:
Authorized Official - Last Name:SYKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-484-4472
Mailing Address - Street 1:810 KILARNEY DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-6558
Mailing Address - Country:US
Mailing Address - Phone:571-484-4472
Mailing Address - Fax:
Practice Address - Street 1:1116 S CHURCH ST
Practice Address - Street 2:
Practice Address - City:MOUNT OLIVE
Practice Address - State:NC
Practice Address - Zip Code:28365-2504
Practice Address - Country:US
Practice Address - Phone:919-299-4539
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-26
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No251S00000XAgenciesCommunity/Behavioral Health
No347C00000XTransportation ServicesPrivate Vehicle