Organization
FOUNTAIN OF YOUTH, LLC
Active
Other names
Seelyville Family Practice
Organization subpart
No
Provider details
NPI number
Authorized official
SHERRI JERNBERG NP (OWNER/OPERATOR)
(812) 239-4090
Entity
Organization
Contact information
Practice address
8810 WABASH AVE, TERRE HAUTE, IN 47803-3908
(812) 239-4090
Mailing address
8810 WABASH AVE, TERRE HAUTE, IN 47803-3908
(812) 239-4090
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
71002624A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1588821250
PERSONAL NPI NUMBER
IN
Enumeration date
04/30/2012
Last updated
04/30/2012
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