Provider Demographics
NPI:1699455956
Name:FOUNTAIN LIFE ORLANDO, LLC
Entity type:Organization
Organization Name:FOUNTAIN LIFE ORLANDO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLINICAL OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-725-1516
Mailing Address - Street 1:6424 ALEXANDRA LOUISE DR STE 120
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827-5812
Mailing Address - Country:US
Mailing Address - Phone:917-810-8672
Mailing Address - Fax:
Practice Address - Street 1:6424 ALEXANDRA LOUISE DR STE 120
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-5812
Practice Address - Country:US
Practice Address - Phone:917-810-8672
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-21
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center