Basic Information
| Provider Information | |||||||||
| NPI: | 1437240447 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANDERLAAN | ||||||||
| FirstName: | VICKIE | ||||||||
| MiddleName: | L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1675 LEAHY ST | ||||||||
| Address2: | STE 109 | ||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494425500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317285720 | ||||||||
| FaxNumber: | 2317285721 | ||||||||
| Practice Location | |||||||||
| Address1: | 1675 LEAHY ST | ||||||||
| Address2: | STE 109 | ||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494425500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317285720 | ||||||||
| FaxNumber: | 2317285721 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 05/01/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | 1601000084 | MI | Y | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | 540F111730 | 01 | MI | BCBS SUPPLIER ID | OTHER | 904900723 | 05 | MI | MEDICAID | 640F12603 | 01 | MI | BCBS AUDIO ID | OTHER |