Provider Demographics
NPI:1417361882
Name:FORTUNE, MATTHEW (LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:FORTUNE
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5705 SHATTALON DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27105-1332
Mailing Address - Country:US
Mailing Address - Phone:336-399-5668
Mailing Address - Fax:
Practice Address - Street 1:5705 SHATTALON DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-1332
Practice Address - Country:US
Practice Address - Phone:336-399-5668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22372255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer