Basic Information
| Provider Information | |||||||||
| NPI: | 1871650994 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOUNTAIN PARK HOME CARE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 W. MAIN ST. | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | VAN WERT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458911704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192380715 | ||||||||
| FaxNumber: | 4192381625 | ||||||||
| Practice Location | |||||||||
| Address1: | 1112 S WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | VAN WERT | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458912409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192383133 | ||||||||
| FaxNumber: | 4192381625 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2007 | ||||||||
| LastUpdateDate: | 02/17/2020 | ||||||||
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| AuthorizedOfficialLastName: | STEWART | ||||||||
| AuthorizedOfficialFirstName: | SHANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4192380715 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 368142 | OH | Y | Agencies | Home Health |
No ID Information.