Provider Demographics
NPI:1578765087
Name:FOUNTAIN FOOT CLINIC PC
Entity Type:Organization
Organization Name:FOUNTAIN FOOT CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:MEIER
Authorized Official - Last Name:FOUNTAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:402-466-5677
Mailing Address - Street 1:5835 VINE ST
Mailing Address - Street 2:PO BOX 5505
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68505-2847
Mailing Address - Country:US
Mailing Address - Phone:402-466-5677
Mailing Address - Fax:
Practice Address - Street 1:5835 VINE ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68505-2847
Practice Address - Country:US
Practice Address - Phone:402-466-5677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE218213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE505963785Medicaid
NE480013496OtherRR MC
NE086360Medicare ID - Type Unspecified
NE480013496OtherRR MC