Provider Demographics
NPI:1588773097
Name:FONTAINE CHIROPRACTIC WELLNESS CENTER
Entity type:Organization
Organization Name:FONTAINE CHIROPRACTIC WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:FONTAINE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:256-891-2229
Mailing Address - Street 1:623 BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:ALBERTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35950-2976
Mailing Address - Country:US
Mailing Address - Phone:256-891-2229
Mailing Address - Fax:
Practice Address - Street 1:623 BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:ALBERTVILLE
Practice Address - State:AL
Practice Address - Zip Code:35950-2976
Practice Address - Country:US
Practice Address - Phone:256-891-2229
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1772111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALU65407Medicare UPIN