Provider Demographics
NPI:1043265887
Name:LIFE FOUNTAIN HEALTH CARE, INC
Entity type:Organization
Organization Name:LIFE FOUNTAIN HEALTH CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ADEGBOLA
Authorized Official - Middle Name:ADEJISOLA
Authorized Official - Last Name:ADEGOKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-454-6865
Mailing Address - Street 1:11115 NEW HALLS FERRY RD
Mailing Address - Street 2:202
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-7613
Mailing Address - Country:US
Mailing Address - Phone:314-830-3840
Mailing Address - Fax:314-830-3820
Practice Address - Street 1:1115 NEW HALLS FERRY RD
Practice Address - Street 2:202
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63033
Practice Address - Country:US
Practice Address - Phone:314-830-3840
Practice Address - Fax:314-830-3820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
267611OtherPTAN NUMBER