MEDICARE: FOUNTAIN COMMUNITY HEALTHCARE SERVICES

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	253Z00000X	In Home Supportive Care Agency
2	385H00000X	Respite Care
3	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1750738506
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOUNTAIN COMMUNITY HEALTHCARE SERVICES

Provider Business Mailing Address
First Line	:	111 FAWN RUN DR
Second Line	:
City	:	GEORGETOWN
State	:	KY
Zip	:	40324-8402
Country	:	US
Telephone Number	:	502-542-0964
Fax Number	:	502-868-9152

Provider Business Practice Location Address
First Line	:	1232 PARIS PIKE
Second Line	:
City	:	GEORGETOWN
State	:	KY
Zip	:	40324-9701
Country	:	US
Telephone Number	:	502-542-0964
Fax Number	:	502-868-9152

Authorized Official
Title or Position	:	CEO
Name	:	DR. STEPHEN KOFI KPONYOH
Credential	:	M.D,MBA
Telephone Number	:	502-542-0964

Provider Enumeration Date	:	05/23/2016
Last Update Date	:	05/23/2016

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