Basic Information
| Provider Information | |||||||||
| NPI: | 1184652299 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANDENBERG | ||||||||
| FirstName: | VERNON | ||||||||
| MiddleName: | JACK | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 286 HOOVER BLVD | ||||||||
| Address2: | |||||||||
| City: | HOLLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494233719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163922172 | ||||||||
| FaxNumber: | 6163921726 | ||||||||
| Practice Location | |||||||||
| Address1: | 286 HOOVER BLVD | ||||||||
| Address2: | |||||||||
| City: | HOLLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494233719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163922172 | ||||||||
| FaxNumber: | 6163921726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 09/01/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501001113 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1184652299 | 01 | MI | NPI | OTHER | 1649216144 | 01 | MI | GROUP NPI | OTHER | 650G011870 | 01 | MI | BCBSM | OTHER | 5501001113 | 01 | MI | STATE OF MICHIGAN | OTHER |