Healthcare Provider Details

I. General information

NPI: 1013310309
Provider Name (Legal Business Name): FOUNTAIN VALLEY GROUP SERVICES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2014
Last Update Date: 10/25/2024
Certification Date: 10/25/2024
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 SUITE 320
ATLANTA GA
30328-5831
US

V. Phone/Fax

Practice location:
  • Phone: 760-347-6191
  • Fax:
Mailing address:
  • Phone: 770-874-5400
  • Fax: 770-874-5483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: KIM LARSEN
Title or Position: VP, CREDENTIALING
Credential:
Phone: 770-874-5400