MEDICARE: DR. JEAN H FONTAINE D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	1772	AL
2	111NR0400X	Rehabilitation Chiropractor	DC010306	PA

General Provider Information

NPI Number	:	1891804498
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEAN H FONTAINE D.C.

Provider Business Mailing Address
First Line	:	7205 RISING SUN AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19111-3926
Country	:	US
Telephone Number	:	215-276-2250
Fax Number	:	215-276-2110

Provider Business Practice Location Address
First Line	:	7205 RISING SUN AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19111-3926
Country	:	US
Telephone Number	:	215-276-2250
Fax Number	:	215-276-2110

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	08/05/2015

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