Fountain of Youth, LLC

Primary specialty

Clinic/CenterTaxonomy code 261Q00000X

License

71002624A Issued in IN

Legal business name

FOUNTAIN OF YOUTH, LLC

Doing business as

Seelyville Family Practice

Practice address

8810 Wabash Ave
Terre Haute, IN 47803-3908

Phone

(812) 239-4090

NPI assigned

Apr 30, 2012

Organization subpart

No

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

Authorized official

Name

Sherri Jernberg, NP

Title

Owner/Operator

Phone

(812) 239-4090

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Seelyville Family Practice Doing business as

Locations

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

{
    "created_epoch": "1335744000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1335744000000",
    "number": "1316205115",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8810 WABASH AVE",
            "city": "TERRE HAUTE",
            "state": "IN",
            "postal_code": "478033908",
            "telephone_number": "812-239-4090"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8810 WABASH AVE",
            "city": "TERRE HAUTE",
            "state": "IN",
            "postal_code": "478033908",
            "telephone_number": "812-239-4090"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FOUNTAIN OF YOUTH, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-04-30",
        "last_updated": "2012-04-30",
        "status": "A",
        "authorized_official_last_name": "JERNBERG",
        "authorized_official_first_name": "SHERRI",
        "authorized_official_title_or_position": "OWNER/OPERATOR",
        "authorized_official_telephone_number": "812-239-4090",
        "authorized_official_credential": "NP"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": "IN",
            "license": "71002624A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PERSONAL NPI NUMBER",
            "identifier": "1588821250",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Seelyville Family Practice",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Benjamin Forsythe
• Forward by Highland
• Avery Foster
• Stephanie Fougerousse, DO
• James H Foulkes, DDS
• Ednita Charzette Street Fountain, DNP, CRNA
• Kirsten Marie Fox, LCSW
• Angela Kay Francis, M.S., CCC-SLP
• Kacey Franklin
• Kayla Franklin, RBT

• Clinic/Center in Terre Haute, IN
• Providers in Terre Haute, IN by specialty
• Clinic/Center in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 30, 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.