Provider Demographics
NPI:1740320548
Name:FOUNTAIN VILLA RESIDENTIAL CARE
Entity type:Organization
Organization Name:FOUNTAIN VILLA RESIDENTIAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:C
Authorized Official - Last Name:MONSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-365-6002
Mailing Address - Street 1:2620 N KENTUCKY ST
Mailing Address - Street 2:
Mailing Address - City:IOLA
Mailing Address - State:KS
Mailing Address - Zip Code:66749-1940
Mailing Address - Country:US
Mailing Address - Phone:620-365-6002
Mailing Address - Fax:620-365-3510
Practice Address - Street 1:2620 N KENTUCKY ST
Practice Address - Street 2:
Practice Address - City:IOLA
Practice Address - State:KS
Practice Address - Zip Code:66749-1940
Practice Address - Country:US
Practice Address - Phone:620-365-6002
Practice Address - Fax:620-365-3510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSN001-006302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization