Provider Demographics
NPI:1578642054
Name:FOUNTAIN HOUSE, INC.
Entity Type:Organization
Organization Name:FOUNTAIN HOUSE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:DUDEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-582-0340
Mailing Address - Street 1:425 W 47TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-2304
Mailing Address - Country:US
Mailing Address - Phone:212-582-0340
Mailing Address - Fax:212-957-1424
Practice Address - Street 1:425 W 47TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-2304
Practice Address - Country:US
Practice Address - Phone:212-582-0340
Practice Address - Fax:212-957-1424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY01303502302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization