Organization
FOUNTAIN OF LIFE HOME HEALTHCARE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. GREGORY STEVENSON (OWNER)
(414) 716-6146
Entity
Organization
Contact information
Practice address
11414 W PARK PL STE 202, MILWAUKEE, WI 53224-3500
(414) 716-6146
(414) 509-1635
Mailing address
11414 W PARK PL STE 202, MILWAUKEE, WI 53224-3500
(414) 716-6146
(414) 509-1635
Taxonomy
Speciality
Code
Description
License number
State
251E00000X
Home Health Agency
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100102050
—
WI
Enumeration date
09/14/2020
Last updated
09/14/2020
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