MEDICARE: DR. AMIKO SUE FOUNTAIN DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	CHIR008451	GA
2	111N00000X	Chiropractor	8118	AZ

General Provider Information

NPI Number	:	1073748273
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMIKO SUE FOUNTAIN DC

Provider Business Mailing Address
First Line	:	13660 N 94TH DR STE C4
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85381-4841
Country	:	US
Telephone Number	:	602-502-2319
Fax Number	:

Provider Business Practice Location Address
First Line	:	1950 SPECTRUM CIR SE STE 400
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30067-1638
Country	:	US
Telephone Number	:	678-541-4357
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2009
Last Update Date	:	05/17/2010

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Directions to “ DR. AMIKO SUE FOUNTAIN DC” Practice Location

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