Provider Demographics
NPI:1710323993
Name:FOUNTAIN OF LIFE CHIROPRACTIC PC
Entity Type:Organization
Organization Name:FOUNTAIN OF LIFE CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:NICHOLAS
Authorized Official - Last Name:FOUNTAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:906-440-9272
Mailing Address - Street 1:267 CREEKSIDE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-7609
Mailing Address - Country:US
Mailing Address - Phone:231-347-1776
Mailing Address - Fax:231-347-1778
Practice Address - Street 1:267 CREEKSIDE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-7609
Practice Address - Country:US
Practice Address - Phone:231-347-1776
Practice Address - Fax:231-347-1778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-15
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty