1447508015 NPI number — FOUNTAIN CHIROPRACTIC CLINIC, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447508015 NPI number — FOUNTAIN CHIROPRACTIC CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUNTAIN CHIROPRACTIC CLINIC, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447508015
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2728 ASBURY RD.
Provider Second Line Business Mailing Address:
SUITE 920
Provider Business Mailing Address City Name:
DUBUQUE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52001-2970
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-582-5185
Provider Business Mailing Address Fax Number:
563-582-3075

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2728 ASBURY RD.
Provider Second Line Business Practice Location Address:
SUITE 920
Provider Business Practice Location Address City Name:
DUBUQUE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52001-2970
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-582-5185
Provider Business Practice Location Address Fax Number:
563-582-3075
Provider Enumeration Date:
08/29/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
LEE
Authorized Official Middle Name:
JOSEPH
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
563-582-5185

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  06478 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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