Provider Demographics
NPI:1417082421
Name:FOUNTAINS THERAPY CENTER
Entity Type:Organization
Organization Name:FOUNTAINS THERAPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SERGIO
Authorized Official - Middle Name:MAURICO
Authorized Official - Last Name:TRIANA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:954-424-9724
Mailing Address - Street 1:817 S UNIVERSITY DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3309
Mailing Address - Country:US
Mailing Address - Phone:954-424-9724
Mailing Address - Fax:954-424-9533
Practice Address - Street 1:817 S UNIVERSITY DR
Practice Address - Street 2:SUITE 105
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-3309
Practice Address - Country:US
Practice Address - Phone:954-424-9724
Practice Address - Fax:954-424-9533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7549111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL76940OtherPRV#BS