Provider Demographics
NPI:1407491475
Name:FOUNTAIN GATE HEALTH LLC
Entity Type:Organization
Organization Name:FOUNTAIN GATE HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:EVELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCARTHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-516-8304
Mailing Address - Street 1:10714 ILEX ST NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-4941
Mailing Address - Country:US
Mailing Address - Phone:763-516-8304
Mailing Address - Fax:
Practice Address - Street 1:10714 ILEX ST NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-4941
Practice Address - Country:US
Practice Address - Phone:763-516-8304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness