Provider Demographics
NPI:1912020033
Name:FOUNTAIN OF LIFE FAMILY CHIROPRACTIC, INC.
Entity Type:Organization
Organization Name:FOUNTAIN OF LIFE FAMILY CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:KNUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:816-741-4711
Mailing Address - Street 1:8335 N CONGRESS AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64152-2041
Mailing Address - Country:US
Mailing Address - Phone:816-741-4711
Mailing Address - Fax:816-741-0119
Practice Address - Street 1:8335 N CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64152-2041
Practice Address - Country:US
Practice Address - Phone:816-741-4711
Practice Address - Fax:816-741-0119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty