Provider Demographics
NPI:1962091686
Name:FOUNTAIN OF HEALTH HOME HEALTH AGENCY LLC
Entity type:Organization
Organization Name:FOUNTAIN OF HEALTH HOME HEALTH AGENCY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:OLUGBENGA
Authorized Official - Middle Name:
Authorized Official - Last Name:AYENI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-428-2259
Mailing Address - Street 1:1420 BRUMMEL ST
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-3706
Mailing Address - Country:US
Mailing Address - Phone:847-859-6217
Mailing Address - Fax:847-859-6227
Practice Address - Street 1:5875 N LINCOLN AVE STE 243
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-4668
Practice Address - Country:US
Practice Address - Phone:847-859-6217
Practice Address - Fax:847-859-6227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-16
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No251E00000XAgenciesHome Health