Basic Information
| Provider Information | |||||||||
| NPI: | 1710964184 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANCAMPEN | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MSPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 685 36TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973014741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035408701 | ||||||||
| FaxNumber: | 5033718772 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 MCNARY ESTATES DR N | ||||||||
| Address2: | |||||||||
| City: | KEIZER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034635231 | ||||||||
| FaxNumber: | 5034635175 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2005 | ||||||||
| LastUpdateDate: | 04/05/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 3846 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 298482 | 05 | OR | MEDICAID |