Healthcare Provider Details

I. General information

NPI: 1104151273
Provider Name (Legal Business Name): FOUNTAIN RESOURCES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2009
Last Update Date: 03/10/2021
Certification Date: 03/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8900 WILSHIRE BLVD
BEVERLY HILLS CA
90211-1958
US

IV. Provider business mailing address

12011 SAN VICENTE BLVD STE 402
LOS ANGELES CA
90049-4946
US

V. Phone/Fax

Practice location:
  • Phone: 310-208-0708
  • Fax:
Mailing address:
  • Phone: 310-766-8597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number005347
License Number StateNY

VIII. Authorized Official

Name: MS. CAROLYN KATZIN
Title or Position: PRESIDENT
Credential: MS, CNS
Phone: 310-766-8597