=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710323993
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOUNTAIN OF LIFE CHIROPRACTIC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2013
-----------------------------------------------------
Last Update Date | 05/15/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 267 CREEKSIDE DR SUITE 100
-----------------------------------------------------
City | PETOSKEY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49770-7609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-347-1776
-----------------------------------------------------
Fax | 231-347-1778
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 267 CREEKSIDE DR SUITE 100
-----------------------------------------------------
City | PETOSKEY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49770-7609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-347-1776
-----------------------------------------------------
Fax | 231-347-1778
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DR. JUSTIN NICHOLAS FOUNTAIN
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 906-440-9272
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------