Provider Demographics
NPI:1619033354
Name:FOUNTAIN IMAGING OF WEST PALM BEACH
Entity Type:Organization
Organization Name:FOUNTAIN IMAGING OF WEST PALM BEACH
Other - Org Name:FOUNTAIN IMAGING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HEBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-688-7309
Mailing Address - Street 1:5841 CORPORATE WAY
Mailing Address - Street 2:SUITE #101
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-2039
Mailing Address - Country:US
Mailing Address - Phone:561-688-7309
Mailing Address - Fax:561-688-7310
Practice Address - Street 1:5841 CORPORATE WAY
Practice Address - Street 2:SUITE #101
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-2039
Practice Address - Country:US
Practice Address - Phone:561-688-7309
Practice Address - Fax:561-688-7310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC4508261QM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU0077Medicare ID - Type Unspecified