Provider Demographics
NPI:1114083847
Name:FOUNTAIN IMAGING OF PEMBROKE PINES,LLC
Entity Type:Organization
Organization Name:FOUNTAIN IMAGING OF PEMBROKE PINES,LLC
Other - Org Name:FOUNTAIN IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HEBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-983-4266
Mailing Address - Street 1:2221 N UNIVERSITY DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-3603
Mailing Address - Country:US
Mailing Address - Phone:954-983-4266
Mailing Address - Fax:954-983-4233
Practice Address - Street 1:2221 N UNIVERSITY DR
Practice Address - Street 2:SUITE A
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-3603
Practice Address - Country:US
Practice Address - Phone:954-983-4266
Practice Address - Fax:954-983-4233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC7166261QM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU3511Medicare ID - Type Unspecified