Provider Demographics
NPI:1528673738
Name:FOUNTAIN OF LIFE HOME HEALTHCARE
Entity type:Organization
Organization Name:FOUNTAIN OF LIFE HOME HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:STEVENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-716-6146
Mailing Address - Street 1:11414 W PARK PL STE 202
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53224-3500
Mailing Address - Country:US
Mailing Address - Phone:414-716-6146
Mailing Address - Fax:414-509-1635
Practice Address - Street 1:11414 W PARK PL STE 202
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53224-3500
Practice Address - Country:US
Practice Address - Phone:414-716-6146
Practice Address - Fax:414-509-1635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100102050Medicaid