FOUNTAIN OF YOUTH LLC RESIDENTIAL CARE — NPI 1306608195 (Licensed & Credentialed Custodial Care Facility, Adult Care Home in MOUNT OLIVE, NC)

CMS-1500 Box 24J / 33a • NPI

1306608195

Type 2 Organization (Box 32a/33a)

HIPAA NUCC Taxonomy • CMS Code

311ZA0620X

Licensed & Credentialed Custodial Care Facility, Adult Care Home

Box 32 Service Location & ZIP+4

1116 S CHURCH ST, MOUNT OLIVE, NC, 28365-2504

✓ 9-Digit EDI 837 ZIP+4 (28365-2504)

Practice Phone & Referral Fax

(919) 299-4539

Direct NPPES Verification Line

✓ HHS OIG LEIE Sanction Screening — VERIFIED CLEAR: NPI 1306608195 (FOUNTAIN OF YOUTH LLC RESIDENTIAL CARE) has 0 active federal exclusions across all 84,224 HHS OIG LEIE sanction records (Database Verified: 2026-11-11).

CMS Medicare Order & Referring PECOS Eligibility

Institutional Type-2 NPI facilities enroll via CMS-855A institutional provider agreements rather than individual Order & Referring PECOS.

Official CMS NPPES Credential & Practice Profile

10-Digit NPI Number	`1306608195` (NPI-2 Organization / Facility)
Provider / Legal Name	FOUNTAIN OF YOUTH LLC RESIDENTIAL CARE
Plain-English Specialty	Licensed & Credentialed Custodial Care Facility, Adult Care Home NUCC Code: `311ZA0620X` (Custodial Care Facility, Adult Care Home)
Certifying / Licensing Body	State Medical / Healthcare Licensing Board & National Specialty Board
Practice Location Address	1116 S CHURCH ST, MOUNT OLIVE, NC, 28365-2504
Practice Telephone / Fax	Tel: (919) 299-4539
Administrative Mailing Address	810 KILARNEY DR, FREDERICKSBURG, VA, 22407-6558
Enumeration & Last Sync	Enumerated: 2024-01-26 \| CMS Record Updated: 2025-01-13
Authorized Official	SADIO SYKES (Administer)

Clinic Location, Accessibility & Directions

📍 Practice Location & Patient Access

1116 S CHURCH ST, MOUNT OLIVE, NC, 28365-2504

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Plain-English Taxonomy & CMS Crosswalk (311ZA0620X)

What Does Taxonomy Code 311ZA0620X Mean?

In the HIPAA National Uniform Claim Committee (NUCC) classification, code 311ZA0620X translates to:
"Licensed & Credentialed Custodial Care Facility, Adult Care Home"

CMS-1500 Medicare Specialty Crosswalk: Standard HIPAA X12N 837P / CMS-1500
Certifying / Accrediting Authority: State Medical / Healthcare Licensing Board & National Specialty Board
Clinical Scope: Consult a verified Custodial Care Facility, Adult Care Home for specialized diagnostic evaluation, treatment planning, and continuity of care.

Specialty Clinical Procedures & Therapeutic Classes

Standard Scope of Care (FOUNTAIN OF YOUTH LLC RESIDENTIAL CARE)

Typical CPT / Diagnostic Procedures:

Comprehensive Outpatient & Inpatient Clinical Evaluation (CPT 99202–99215)
Diagnostic Workup, Laboratory Ordering & Evidence-Based Care Coordination
Preventive Screening, Patient Counseling & Multidisciplinary Referral

Common Therapeutic Classes:

Evidence-Based Specialty Pharmacotherapy & Preventive Regimens (CMS Part D Standard)

All Registered NUCC Taxonomies & State Licenses

Taxonomy Code & Plain-English Description	State License & Primary Status
`251S00000X` — Community/Behavioral Health Plain English: Licensed & Credentialed Community/Behavioral Health	State: N/A \| License: `Verified` \| Primary: Secondary
`311ZA0620X` — Custodial Care Facility, Adult Care Home Plain English: Licensed & Credentialed Custodial Care Facility, Adult Care Home	State: N/A \| License: `Verified` \| Primary: Yes (Primary)
`347C00000X` — Private Vehicle Plain English: Licensed & Credentialed Private Vehicle	State: N/A \| License: `Verified` \| Primary: Secondary

Medical Billing, RCM & Hospital Credentialing Teams:

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FOUNTAIN OF YOUTH LLC RESIDENTIAL CARE (NPI #1306608195)