Provider Demographics
NPI:1326261553
Name:FOUNTAIN LAKE SCHOOL
Entity Type:Organization
Organization Name:FOUNTAIN LAKE SCHOOL
Other - Org Name:SPECIAL EDUCATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SPECIAL EDUCATION SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:EUBANKS
Authorized Official - Suffix:
Authorized Official - Credentials:MSE
Authorized Official - Phone:501-701-1768
Mailing Address - Street 1:4207 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71901-9473
Mailing Address - Country:US
Mailing Address - Phone:501-262-5950
Mailing Address - Fax:501-262-5960
Practice Address - Street 1:4207 PARK AVE
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-9473
Practice Address - Country:US
Practice Address - Phone:501-262-5950
Practice Address - Fax:501-262-5960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR124346743Medicaid