Provider Demographics
NPI:1750128229
Name:FOUNTAINHEAD BROS LLC
Entity type:Organization
Organization Name:FOUNTAINHEAD BROS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:B
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:435-574-4424
Mailing Address - Street 1:92 N 3400 W # 1
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:UT
Mailing Address - Zip Code:84737-3023
Mailing Address - Country:US
Mailing Address - Phone:435-574-4424
Mailing Address - Fax:
Practice Address - Street 1:92 N 3400 W # 1
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:UT
Practice Address - Zip Code:84737-3023
Practice Address - Country:US
Practice Address - Phone:435-574-4424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty