Provider Demographics
NPI:1245390459
Name:FOUNTAIN CITY EYECARE LLC
Entity Type:Organization
Organization Name:FOUNTAIN CITY EYECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:NICHOLAS
Authorized Official - Last Name:EISCHENS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:334-358-2440
Mailing Address - Street 1:1807 STATION DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:PRATTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36066-5664
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1807 STATION DR
Practice Address - Street 2:SUITE A
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36066-5664
Practice Address - Country:US
Practice Address - Phone:334-358-2440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS983TA555152W00000X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051509621OtherBCBS
AL22-00012OtherUNITED HEALTHCARE
AL529911890Medicaid
P00201800OtherRAILROAD MEDICARE
AL051509621Medicaid
AL529911890Medicaid
AL=========OtherVIVA HEALTHCARE INC
AL=========OtherVIVA HEALTHCARE INC
AL051509621Medicaid