Provider Demographics
NPI:1215533757
Name:FOUNTAIN ASSISSTED LIVING CENTER LLC
Entity type:Organization
Organization Name:FOUNTAIN ASSISSTED LIVING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIRSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-206-4241
Mailing Address - Street 1:3048 E BASELINE RD
Mailing Address - Street 2:STE 108
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204
Mailing Address - Country:US
Mailing Address - Phone:480-206-4241
Mailing Address - Fax:
Practice Address - Street 1:2260 E BROWN ROAD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-5224
Practice Address - Country:US
Practice Address - Phone:480-299-3310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-09
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ103616Medicaid