Provider Demographics
NPI:1154487668
Name:FOUNTAIN IMAGING GROUP,LLC
Entity Type:Organization
Organization Name:FOUNTAIN IMAGING GROUP,LLC
Other - Org Name:FOUNTAIN IMAGING
Other - Org Type:Other Name
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:305-770-4343
Mailing Address - Street 1:1 NE 167TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-3402
Mailing Address - Country:US
Mailing Address - Phone:305-770-4343
Mailing Address - Fax:305-770-4373
Practice Address - Street 1:1 NE 167TH ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-3402
Practice Address - Country:US
Practice Address - Phone:305-770-4343
Practice Address - Fax:305-770-4373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center