Provider Demographics
NPI:1013467323
Name:FOUNTAIN CHIRO LLC
Entity Type:Organization
Organization Name:FOUNTAIN CHIRO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:ROSS
Authorized Official - Last Name:FOUNTAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-652-7259
Mailing Address - Street 1:24640 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:FLAT ROCK
Mailing Address - State:MI
Mailing Address - Zip Code:48134-9226
Mailing Address - Country:US
Mailing Address - Phone:734-782-0200
Mailing Address - Fax:734-782-0200
Practice Address - Street 1:24640 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:FLAT ROCK
Practice Address - State:MI
Practice Address - Zip Code:48134-9226
Practice Address - Country:US
Practice Address - Phone:734-782-0200
Practice Address - Fax:734-782-0200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-11
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009847111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty