Fountain Healthcare Limited Liability Company

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

Legal business name

FOUNTAIN HEALTHCARE LIMITED LIABILITY COMPANY

Doing business as

LifeRx

Practice address

2412 E Washington St Ste 6
Bloomington, IL 61704-4497

Phone

(309) 585-2116

Fax

(309) 585-2152

NPI assigned

Nov 20, 2012

Organization subpart

No

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

Authorized official

Name

Mr. Clyde L Bass III

Title

President

Phone

(415) 754-3379

Specialties & licenses 1

Addresses

Other names 1

• LifeRx Doing business as

Tax ID family

Fountain Healthcare Limited Liability Company2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• Fountain Healthcare Limited Liability Company

  • Adult Medicine Physician
  • Streator, IL
  • NPI 1730425851
  NPD tax ID

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

{
    "created_epoch": "1353369600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1474416000000",
    "number": "1902140585",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "612 E PERU ST",
            "city": "PRINCETON",
            "state": "IL",
            "postal_code": "613561852",
            "telephone_number": "415-754-3379"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2412 E WASHINGTON ST STE 6",
            "city": "BLOOMINGTON",
            "state": "IL",
            "postal_code": "617044497",
            "telephone_number": "309-585-2116",
            "fax_number": "309-585-2152"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FOUNTAIN HEALTHCARE LIMITED LIABILITY COMPANY",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-11-20",
        "last_updated": "2016-09-21",
        "status": "A",
        "authorized_official_last_name": "BASS",
        "authorized_official_first_name": "CLYDE",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "415-754-3379",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_name_suffix": "III"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "LifeRx",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Victoria N Folse, PHD, APN, LCPC
• Food Stuff, Inc.
• Forward Living LTD
• Ashley Foster, OD
• Phillip Arthur Foster, PH.D.
• Piper Fowler
• Dennis P Fox, D.D.S.
• Barbara Lynn Fraher
• Jennifer Michelle Frances
• Callie Francisco

• Family Medicine Physician in Bloomington, IL
• Providers in Bloomington, IL by specialty
• Family Medicine Physician in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 21, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.