Provider Demographics
NPI:1437169836
Name:FOUNTAIN PLACE REHAB INC
Entity Type:Organization
Organization Name:FOUNTAIN PLACE REHAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ABEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:BORROMEO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:304-752-4045
Mailing Address - Street 1:118 NICK SAVAS DR
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-3468
Mailing Address - Country:US
Mailing Address - Phone:304-752-4045
Mailing Address - Fax:304-752-4045
Practice Address - Street 1:118 NICK SAVAS DR
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3468
Practice Address - Country:US
Practice Address - Phone:304-752-4045
Practice Address - Fax:304-752-4045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U66193Medicare UPIN