Provider Demographics
NPI:1003991183
Name:FOUNTAIN OPTOMETRY, P.C.
Entity Type:Organization
Organization Name:FOUNTAIN OPTOMETRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:FOUNTAIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:734-439-2020
Mailing Address - Street 1:7 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:MI
Mailing Address - Zip Code:48160-1248
Mailing Address - Country:US
Mailing Address - Phone:734-439-2020
Mailing Address - Fax:734-439-2047
Practice Address - Street 1:7 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:MI
Practice Address - Zip Code:48160-1248
Practice Address - Country:US
Practice Address - Phone:734-439-2020
Practice Address - Fax:734-439-2047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004264152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6230060001Medicare NSC