Provider Demographics
NPI:1033492756
Name:FOUNTAIN, GREG ROSS (DC)
Entity Type:Individual
Prefix:DR
First Name:GREG
Middle Name:ROSS
Last Name:FOUNTAIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24640 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:FLAT ROCK
Mailing Address - State:MI
Mailing Address - Zip Code:48134-9226
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24640 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:FLAT ROCK
Practice Address - State:MI
Practice Address - Zip Code:48134-9226
Practice Address - Country:US
Practice Address - Phone:734-652-7259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009847111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor