Provider Demographics
NPI:1447508015
Name:FOUNTAIN CHIROPRACTIC CLINIC, INC.
Entity type:Organization
Organization Name:FOUNTAIN CHIROPRACTIC CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:563-582-5185
Mailing Address - Street 1:2728 ASBURY RD.
Mailing Address - Street 2:SUITE 920
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52001-2970
Mailing Address - Country:US
Mailing Address - Phone:563-582-5185
Mailing Address - Fax:563-582-3075
Practice Address - Street 1:2728 ASBURY RD.
Practice Address - Street 2:SUITE 920
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-2970
Practice Address - Country:US
Practice Address - Phone:563-582-5185
Practice Address - Fax:563-582-3075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06478111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty