1598719510 NPI number — FOUNTAINS BRONSON PLACE SL, LLC

Table of content: (NPI 1598719510)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598719510 NPI number — FOUNTAINS BRONSON PLACE SL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUNTAINS BRONSON PLACE SL, LLC
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:
6
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:
1598719510
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2020 W RUDASILL RD
Provider Second Line Business Mailing Address:
ATTN: MEDICARE BILLING
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85704-7800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-797-4000
Provider Business Mailing Address Fax Number:
520-797-7757

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1451 BRONSON WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KALAMAZOO
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49009-3306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-382-3546
Provider Business Practice Location Address Fax Number:
369-567-5998
Provider Enumeration Date:
05/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FRESHWATER
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
520-797-4000

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  394050 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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