Organization
FOUNTAIN HEALTHCARE LIMITED LIABILITY COMPANY
Active
Other names
LifeRx
Organization subpart
No
Provider details
NPI number
Authorized official
MR. CLYDE L BASS III (PRESIDENT)
(415) 754-3379
Entity
Organization
Contact information
Practice address
2412 E WASHINGTON ST STE 6, BLOOMINGTON, IL 61704-4497
(309) 585-2116
(309) 585-2152
Mailing address
612 E PERU ST, PRINCETON, IL 61356-1852
(415) 754-3379
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Enumeration date
11/20/2012
Last updated
09/21/2016
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