Provider Demographics
NPI:1245645654
Name:LANG, MATTHEW JOHN (MA, AT, ATC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOHN
Last Name:LANG
Suffix:
Gender:M
Credentials:MA, AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 LAKE DR SE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-8292
Mailing Address - Country:US
Mailing Address - Phone:616-581-5296
Mailing Address - Fax:
Practice Address - Street 1:475 W SPARTAN DR
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:MI
Practice Address - Zip Code:49345-8734
Practice Address - Country:US
Practice Address - Phone:616-581-5296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-24
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010013002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer