Fountain of Youth, Inc

Primary specialty

Voluntary or Charitable AgencyTaxonomy code 251V00000X

License

105 Issued in AR

Legal business name

FOUNTAIN OF YOUTH, INC

Practice address

2409 S 56TH St
Suite 121
Fort Smith, AR 72903-3753

Phone

(479) 484-7782

Fax

(479) 484-7951

NPI assigned

Apr 22, 2008

Last updated

Sep 5, 2012By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Michelle Foutch

Title

Site Director

Phone

(479) 484-7782

Specialties & licenses 1

Addresses

Other identifiers 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1208822400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1346803200000",
    "number": "1225202179",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2409 S 56TH ST",
            "address_2": "SUITE 121",
            "city": "FORT SMITH",
            "state": "AR",
            "postal_code": "729033753",
            "telephone_number": "479-484-7782",
            "fax_number": "479-484-7951"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2409 S 56TH ST",
            "address_2": "SUITE 121",
            "city": "FORT SMITH",
            "state": "AR",
            "postal_code": "729033753",
            "telephone_number": "479-484-7782",
            "fax_number": "479-484-7951"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FOUNTAIN OF YOUTH, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-04-22",
        "last_updated": "2012-09-05",
        "status": "A",
        "authorized_official_last_name": "FOUTCH",
        "authorized_official_first_name": "MICHELLE",
        "authorized_official_title_or_position": "SITE DIRECTOR",
        "authorized_official_telephone_number": "479-484-7782"
    },
    "taxonomies": [
        {
            "code": "251V00000X",
            "taxonomy_group": "",
            "desc": "Voluntary or Charitable",
            "state": "AR",
            "license": "105",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "165464755",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Fort Smith Surgical Supply Co
• Christopher Thomas Fortson, M.D.
• John P Foster, MHPP
• Tiffany Leann Foster, APN
• Margaret Foti
• Emily Elizabeth Fourmy, D.D.S.
• Benjamin Foutenot
• Erica Fowler
• Gage Fowler, AGACNP-BC
• Mark J. Fowler, M.D.

• Voluntary or Charitable Agency in Fort Smith, AR
• Providers in Fort Smith, AR by specialty
• Voluntary or Charitable Agency in Arkansas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 5, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.