Provider Demographics
NPI:1902869787
Name:FOUNTAIN LAKE HEALTH AND REHAB INC
Entity Type:Organization
Organization Name:FOUNTAIN LAKE HEALTH AND REHAB INC
Other - Org Name:FOUNTAIN LAKE HEALTH AND REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOEY
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:WIGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-305-3153
Mailing Address - Street 1:2908 HAWKINS DRIVE
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143
Mailing Address - Country:US
Mailing Address - Phone:501-305-3153
Mailing Address - Fax:501-279-3796
Practice Address - Street 1:351 WOODFIN ST
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901
Practice Address - Country:US
Practice Address - Phone:501-624-5238
Practice Address - Fax:501-624-2519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR681314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR015254OtherMEDIPAK
AR015254OtherMEDIPAK