Provider Demographics
NPI:1871650994
Name:FOUNTAIN PARK HOME CARE, LLC
Entity Type:Organization
Organization Name:FOUNTAIN PARK HOME CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-238-0715
Mailing Address - Street 1:120 W. MAIN ST.
Mailing Address - Street 2:SUITE 200
Mailing Address - City:VAN WERT
Mailing Address - State:OH
Mailing Address - Zip Code:45891-1704
Mailing Address - Country:US
Mailing Address - Phone:419-238-0715
Mailing Address - Fax:419-238-1625
Practice Address - Street 1:1112 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891-2409
Practice Address - Country:US
Practice Address - Phone:419-238-3133
Practice Address - Fax:419-238-1625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH368142251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH368142Medicare ID - Type UnspecifiedLICENSE NUMBER