Provider Demographics
NPI:1972739167
Name:FOUNTAIN VENTURES INC
Entity Type:Organization
Organization Name:FOUNTAIN VENTURES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KOFFI
Authorized Official - Middle Name:
Authorized Official - Last Name:AGAMAHHIHEWODO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-239-7111
Mailing Address - Street 1:3926 AVENUE H
Mailing Address - Street 2:24
Mailing Address - City:ROSENBERG
Mailing Address - State:TX
Mailing Address - Zip Code:77471-2842
Mailing Address - Country:US
Mailing Address - Phone:281-239-7111
Mailing Address - Fax:
Practice Address - Street 1:3926 AVENUE H
Practice Address - Street 2:24
Practice Address - City:ROSENBERG
Practice Address - State:TX
Practice Address - Zip Code:77471-2842
Practice Address - Country:US
Practice Address - Phone:281-239-7111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-02
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6365060001Medicare NSC