Basic Information
| Provider Information | |||||||||
| NPI: | 1437640471 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FOUNTAIN INN NURSING & REHABILITATION CENTER INC | ||||||||
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| OtherOrganizationName: | ADVENTHEALTH CARE CENTER WATERMAN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 485 N KELLER RD STE 250 | ||||||||
| Address2: | |||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327517535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079753000 | ||||||||
| FaxNumber: | 4079753090 | ||||||||
| Practice Location | |||||||||
| Address1: | 4501 WATERMAN WAY | ||||||||
| Address2: | |||||||||
| City: | TAVARES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3526094000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2018 | ||||||||
| LastUpdateDate: | 01/02/2019 | ||||||||
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| AuthorizedOfficialLastName: | RODMAN | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASST SECRETARY OF THE BOARD | ||||||||
| AuthorizedOfficialTelephone: | 4079753011 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | FL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 100964700 | 05 | FL | MEDICAID |