Healthcare Provider Details

I. General information

NPI: 1750973723
Provider Name (Legal Business Name): BETH A FOUNTAIN LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2021
Last Update Date: 02/10/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 SAINT MORITZ
GIRDWOOD AK
99587
US

IV. Provider business mailing address

PO BOX 895
GIRDWOOD AK
99587-0895
US

V. Phone/Fax

Practice location:
  • Phone: 269-718-9736
  • Fax:
Mailing address:
  • Phone: 269-718-9736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number110936
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: