MEDICARE: FOUNTAIN IMAGING OF PLANTATION

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	261QM1200X	Magnetic Resonance Imaging (MRI) Clinic/Center	HCC4211	FL

General Provider Information

NPI Number	:	1881750529
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOUNTAIN IMAGING OF PLANTATION

Provider Business Mailing Address
First Line	:	301 NW 84TH AVE
Second Line	:	SUITE #100
City	:	PLANTATION
State	:	FL
Zip	:	33324-1807
Country	:	US
Telephone Number	:	954-888-1816
Fax Number	:	954-476-5238

Provider Business Practice Location Address
First Line	:	301 NW 84TH AVE
Second Line	:	SUITE #100
City	:	PLANTATION
State	:	FL
Zip	:	33324-1807
Country	:	US
Telephone Number	:	954-888-1816
Fax Number	:	954-476-5238

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	KRISTI LYNN HEBERT
Credential	:
Telephone Number	:	954-888-1816

Provider Enumeration Date	:	12/28/2006
Last Update Date	:	08/22/2020

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