Organization
FOUNTAIN OF YOUTH ACTIVITY CENTER, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JOHN PARKER (EXECUTIVE DIRECTOR)
(816) 503-9865
Entity
Organization
Contact information
Practice address
8801 E 63RD ST STE 101, RAYTOWN, MO 64133-4865
(816) 886-0442
(816) 503-9408
Mailing address
8801 E 63RD ST STE 101, RAYTOWN, MO 64133-4865
(816) 503-9865
Taxonomy
Speciality
Code
Description
License number
State
251T00000X
PACE Provider Organization
Primary
—
—
343900000X
Non-emergency Medical Transport (VAN)
—
—
Other
Enumeration date
06/11/2021
Last updated
06/11/2021
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