Provider Demographics
NPI:1306110333
Name:DR. FONTAINE CHIROPRACTIC CLINIC LLC
Entity type:Organization
Organization Name:DR. FONTAINE CHIROPRACTIC CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NAOMI
Authorized Official - Middle Name:
Authorized Official - Last Name:FONTAINE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:941-227-4539
Mailing Address - Street 1:7324 COVE TERRACE
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34231
Mailing Address - Country:US
Mailing Address - Phone:941-365-2373
Mailing Address - Fax:941-951-2270
Practice Address - Street 1:7324 COVE TERRACE
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231
Practice Address - Country:US
Practice Address - Phone:941-365-2373
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-08
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH3406111N00000X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCH3406OtherCHIROPRACTOR
FL1306110333OtherCHIROPRACTOR
TI55871Medicare UPIN