Provider Demographics
NPI:1578700837
Name:FOUNTAIN PARK INN, BRYAN
Entity Type:Organization
Organization Name:FOUNTAIN PARK INN, BRYAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SABO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-270-7627
Mailing Address - Street 1:1433 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:OH
Mailing Address - Zip Code:43506-1053
Mailing Address - Country:US
Mailing Address - Phone:419-633-9191
Mailing Address - Fax:419-633-9192
Practice Address - Street 1:1433 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:OH
Practice Address - Zip Code:43506-1053
Practice Address - Country:US
Practice Address - Phone:419-633-9191
Practice Address - Fax:419-633-9192
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOUNTAIN PARK INN& VILLAS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2410R310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility