Provider Demographics
NPI:1013212489
Name:VANDERLOO, LANCE RICHARD (DC)
Entity Type:Individual
Prefix:DR
First Name:LANCE
Middle Name:RICHARD
Last Name:VANDERLOO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2230 W BURNSIDE ST STE D
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3727
Mailing Address - Country:US
Mailing Address - Phone:971-255-1922
Mailing Address - Fax:971-250-2884
Practice Address - Street 1:2230 W BURNSIDE ST STE D
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3727
Practice Address - Country:US
Practice Address - Phone:971-255-1922
Practice Address - Fax:971-250-2884
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-17
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA007388111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAG8913150OtherMEDICARE PTAN