Provider Demographics
NPI:1598029993
Name:SWEARINGEN, FONTAINE SCOTT
Entity Type:Individual
Prefix:
First Name:FONTAINE
Middle Name:SCOTT
Last Name:SWEARINGEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:SCOTT
Other - Middle Name:
Other - Last Name:SWEARINGEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:29 DOMINGO RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-8256
Mailing Address - Country:US
Mailing Address - Phone:505-466-3199
Mailing Address - Fax:505-466-3199
Practice Address - Street 1:29 DOMINGO RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87508-8256
Practice Address - Country:US
Practice Address - Phone:505-466-3199
Practice Address - Fax:505-466-3199
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-29
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1162225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist