Provider Demographics
NPI:1649891425
Name:FOUNTAIN MEDICAL TRANSPORT LLC
Entity type:Organization
Organization Name:FOUNTAIN MEDICAL TRANSPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWERN
Authorized Official - Prefix:
Authorized Official - First Name:FIDEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NWAZUZU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-919-0667
Mailing Address - Street 1:1727 KING ST STE 137
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-2761
Mailing Address - Country:US
Mailing Address - Phone:304-919-0667
Mailing Address - Fax:
Practice Address - Street 1:1727 KING ST STE 137
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-2761
Practice Address - Country:US
Practice Address - Phone:304-919-0667
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-02
Last Update Date:2020-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)