Healthcare Provider Details

I. General information

NPI: 1609330257
Provider Name (Legal Business Name): DAVID FOUNTAIN RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2019
Last Update Date: 01/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 QUALITY DR
VACAVILLE CA
95688-9494
US

IV. Provider business mailing address

2749 GREY FOX LN
FAIRFIELD CA
94534-1054
US

V. Phone/Fax

Practice location:
  • Phone: 707-624-3434
  • Fax:
Mailing address:
  • Phone: 707-280-2114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number19636
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: