Provider Demographics
NPI:1902140585
Name:FOUNTAIN HEALTHCARE LIMITED LIABILITY COMPANY
Entity type:Organization
Organization Name:FOUNTAIN HEALTHCARE LIMITED LIABILITY COMPANY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BASS
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:415-754-3379
Mailing Address - Street 1:612 E PERU ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:IL
Mailing Address - Zip Code:61356-1852
Mailing Address - Country:US
Mailing Address - Phone:415-754-3379
Mailing Address - Fax:
Practice Address - Street 1:2412 E WASHINGTON ST STE 6
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-4497
Practice Address - Country:US
Practice Address - Phone:309-585-2116
Practice Address - Fax:309-585-2152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-20
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty