Provider Demographics
NPI:1215533757
Name:FOUNTAIN ASSISTED LIVING CENTER
Entity Type:Organization
Organization Name:FOUNTAIN ASSISTED LIVING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:V
Authorized Official - Last Name:WESTBROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-206-3999
Mailing Address - Street 1:3104 E CAMELBACK RD # 1144
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4502
Mailing Address - Country:US
Mailing Address - Phone:480-206-3999
Mailing Address - Fax:
Practice Address - Street 1:2260 E BROWN RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-5224
Practice Address - Country:US
Practice Address - Phone:480-206-3999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility