Basic Information
| Provider Information | |||||||||
| NPI: | 1679913776 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANTASSEL | ||||||||
| FirstName: | LOWELL | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PT | ||||||||
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| OtherLastName: | VANTASSEL | ||||||||
| OtherFirstName: | L | ||||||||
| OtherMiddleName: | MARK | ||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 205 OSCEOLA ST | ||||||||
| Address2: | |||||||||
| City: | LAURIUM | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499132134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9063376500 | ||||||||
| FaxNumber: | 9063376597 | ||||||||
| Practice Location | |||||||||
| Address1: | 960 RAZORBACK DR STE 3 | ||||||||
| Address2: | |||||||||
| City: | HOUGHTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 499312830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9064828201 | ||||||||
| FaxNumber: | 9064822771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2013 | ||||||||
| LastUpdateDate: | 07/03/2013 | ||||||||
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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 | 5501002464 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.