NPIMap

Organization Active NPI

Fountain Park Home Care, LLC

  • Home Health Agency
  • Van Wert, OH
National Provider Identifier
1871650994
Registry record updated Feb 17, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Home Health AgencyTaxonomy code 251E00000X
License
368142 Issued in OH
Legal business name
FOUNTAIN PARK HOME CARE, LLC
Practice address
1112 S Washington St
Van Wert, OH 45891-2409
Phone
(419) 238-3133
Fax
(419) 238-1625
NPI assigned
Jan 2, 2007
Last updated
Feb 17, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 17, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Shane Stewart
Title
Administrator
Phone
(419) 238-0715

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Home Health Agency 251E00000X 368142 OH Primary

Addresses

Primary practice location

1112 S Washington St
Van Wert, OH 45891-2409

Mailing address

120 W. Main St.
Suite 200
Van Wert, OH 45891-1704
Phone (419) 238-0715

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OH

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120323000510 OH Part A Provider - Home Health Agency 3274553458 Practice locations: Van Wert, OH

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1871650994. Details of each certification follow.

Home health agency certification: CCN 368142

Legal name
FOUNTAIN PARK HOME CARE, LLC
Certification status
Active
Provider type (POS)
Home health agency
Participating since
Sep 7, 2006
Last certification
Feb 8, 2018
Ownership / control type
Proprietary
Organization structure
LLCProprietary
Incorporated
Sep 15, 2005 in OH
Enrollment address
1112 South Washington Street
Van Wert, OH 45891

Care Compare: Home health agency

Medicare Care Compare
Listed as
Fountain Park Home Care, LLCCCN 368142 · All quality measures
Overall star rating
3.5 of 5
Ownership
Proprietary
Certified
Sep 7, 2006
Medicare certification status
ActiveFrom the Provider of Services file
Services
Nursing, Medical social, Home health aide, Physical therapy, Speech pathology, Occupational therapy

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
36D1048069Fountain Park Home Care, LLC1112 S Washington St, Van Wert, OH 45891Certificate of waiverNov 20, 2027

National Provider Directory

National Provider Directory

Locations

623 Spring St
Greenville, OH 45331
Phone (937) 316-8441

153 E Spring St
#2
Saint Marys, OH 45885
Phone (866) 826-2778

118 W Main St
Van Wert, OH 45891
Phone (419) 238-3133

Ownership & related parties

All disclosed owners & managing parties 5

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Jon D Bagley Individual 5% Or Greater Direct Ownership Interest Aug 25, 2005 45%
Limited Partnership Interest Aug 25, 2005
Debbie Albers Individual Operational/Managerial Control Jan 1, 2019
Mark Stuart McCleery Individual 5% Or Greater Direct Ownership Interest Aug 25, 2005 10%
Limited Partnership Interest Aug 25, 2005
W-2 Managing Employee Jun 27, 2012
Mark a White Individual 5% Or Greater Direct Ownership Interest Aug 25, 2005 45%
Limited Partnership Interest Aug 25, 2005
Shane Stewart Individual Corporate Director Jan 1, 2020

Practitioners & affiliated clinicians

Affiliated clinicians 31

Clinicians who list this facility as an affiliation in Medicare Care Compare.

View all 31

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1167696000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1581897600000",
    "number": "1871650994",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "120 W. MAIN ST.",
            "address_2": "SUITE 200",
            "city": "VAN WERT",
            "state": "OH",
            "postal_code": "458911704",
            "telephone_number": "419-238-0715",
            "fax_number": "419-238-1625"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1112 S WASHINGTON ST",
            "city": "VAN WERT",
            "state": "OH",
            "postal_code": "458912409",
            "telephone_number": "419-238-3133",
            "fax_number": "419-238-1625"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FOUNTAIN PARK HOME CARE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-02",
        "last_updated": "2020-02-17",
        "certification_date": "2020-02-17",
        "status": "A",
        "authorized_official_last_name": "STEWART",
        "authorized_official_first_name": "SHANE",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "419-238-0715"
    },
    "taxonomies": [
        {
            "code": "251E00000X",
            "taxonomy_group": "",
            "desc": "Home Health",
            "state": "OH",
            "license": "368142",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Van Wert, OH

Sources for this page

Verify at the official NPI Registry.