Healthcare Provider Details

I. General information

NPI: 1144680273
Provider Name (Legal Business Name): LANCE LETOURNEAU ATC, AT, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2016
Last Update Date: 05/12/2022
Certification Date: 05/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7158 BOLINGBROOK DR
PORTAGE MI
49024-3491
US

IV. Provider business mailing address

7158 BOLINGBROOK DR
PORTAGE MI
49024-3491
US

V. Phone/Fax

Practice location:
  • Phone: 989-630-8809
  • Fax:
Mailing address:
  • Phone: 989-630-8809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number26010011907
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: