Healthcare Provider Details

I. General information

NPI: 1194670349
Provider Name (Legal Business Name): FOUNTAIN VALLEY GROUP SERVICES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2026
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47111 MONROE ST
INDIO CA
92201-6739
US

IV. Provider business mailing address

5665 NEW NORTHSIDE DR STE 320
ATLANTA GA
30328-5834
US

V. Phone/Fax

Practice location:
  • Phone: 760-347-6191
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: KIM H LARSEN
Title or Position: VP, CREDENTIALING
Credential:
Phone: 770-874-5468