Basic Information
| Provider Information | |||||||||
| NPI: | 1679065619 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANDYKE | ||||||||
| FirstName: | NATHANIAL | ||||||||
| MiddleName: | LAWRENCE | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 36 S MAIN ST STE B | ||||||||
| Address2: | |||||||||
| City: | TRAVELERS REST | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296901872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8646608200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2018 | ||||||||
| LastUpdateDate: | 06/05/2018 | ||||||||
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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 | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.