Provider Demographics
NPI:1194503169
Name:LAFOUNTAIN, MATT JOHN (CHW)
Entity type:Individual
Prefix:
First Name:MATT
Middle Name:JOHN
Last Name:LAFOUNTAIN
Suffix:
Gender:M
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1740 GLENDORA LN
Mailing Address - Street 2:
Mailing Address - City:ISHPEMING
Mailing Address - State:MI
Mailing Address - Zip Code:49849-2719
Mailing Address - Country:US
Mailing Address - Phone:906-204-0022
Mailing Address - Fax:
Practice Address - Street 1:1414 W FAIR AVE STE 249
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-5406
Practice Address - Country:US
Practice Address - Phone:906-449-2900
Practice Address - Fax:906-449-2945
Is Sole Proprietor?:No
Enumeration Date:2023-09-20
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker