Provider Demographics
NPI:1659677417
Name:FOUNTAIN, JUSTIN NICHOLAS (DC)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:NICHOLAS
Last Name:FOUNTAIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3396 I 75 BUSINESS SPUR
Mailing Address - Street 2:UNIT D
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-3629
Mailing Address - Country:US
Mailing Address - Phone:906-484-1034
Mailing Address - Fax:906-484-1064
Practice Address - Street 1:3396 I 75 BUSINESS SPUR
Practice Address - Street 2:UNIT D
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-3629
Practice Address - Country:US
Practice Address - Phone:906-484-1034
Practice Address - Fax:906-484-1064
Is Sole Proprietor?:No
Enumeration Date:2011-01-26
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009700111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor