Provider Demographics
NPI:1578210308
Name:FOUNTAIN HOMECARE PROVIDERS LLC
Entity Type:Organization
Organization Name:FOUNTAIN HOMECARE PROVIDERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:N
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-549-0490
Mailing Address - Street 1:317 PERSHING AVE
Mailing Address - Street 2:
Mailing Address - City:COLLINGDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19023-4116
Mailing Address - Country:US
Mailing Address - Phone:804-549-0490
Mailing Address - Fax:
Practice Address - Street 1:317 PERSHING AVE
Practice Address - Street 2:
Practice Address - City:COLLINGDALE
Practice Address - State:PA
Practice Address - Zip Code:19023-4116
Practice Address - Country:US
Practice Address - Phone:804-549-0490
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care