Provider Demographics
NPI:1336365543
Name:FOUNTAIN COURT ASSISTED LIVING
Entity Type:Organization
Organization Name:FOUNTAIN COURT ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:
Authorized Official - Last Name:KNOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-432-3352
Mailing Address - Street 1:4610 NE 77TH AVE
Mailing Address - Street 2:SUITE #132
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6789
Mailing Address - Country:US
Mailing Address - Phone:360-449-4524
Mailing Address - Fax:360-449-4525
Practice Address - Street 1:24200 224TH AVE SE
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-7926
Practice Address - Country:US
Practice Address - Phone:425-432-3352
Practice Address - Fax:425-432-1648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WABH1568310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA688752Medicaid