Provider Demographics
NPI:1295191450
Name:FOUNTAIN ADULT HOME CARE, LLC
Entity Type:Organization
Organization Name:FOUNTAIN ADULT HOME CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:WALSTON
Authorized Official - Last Name:MCNEIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-641-4388
Mailing Address - Street 1:303 WILLIAM WALSTON LANE
Mailing Address - Street 2:
Mailing Address - City:TARBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27886-8587
Mailing Address - Country:US
Mailing Address - Phone:252-641-4388
Mailing Address - Fax:252-641-6412
Practice Address - Street 1:303 WILLIAM WALSTON LANE
Practice Address - Street 2:
Practice Address - City:TARBORO
Practice Address - State:NC
Practice Address - Zip Code:27886
Practice Address - Country:US
Practice Address - Phone:252-641-4388
Practice Address - Fax:252-641-6412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-04
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL033012311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home