Provider Demographics
NPI:1184652299
Name:VANDENBERG, VERNON JACK (PT)
Entity Type:Individual
Prefix:
First Name:VERNON
Middle Name:JACK
Last Name:VANDENBERG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:286 HOOVER BLVD
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-3719
Mailing Address - Country:US
Mailing Address - Phone:616-392-2172
Mailing Address - Fax:616-392-1726
Practice Address - Street 1:286 HOOVER BLVD
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3719
Practice Address - Country:US
Practice Address - Phone:616-392-2172
Practice Address - Fax:616-392-1726
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501001113225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1184652299OtherNPI
MI1649216144OtherGROUP NPI
MI650G011870OtherBCBSM
MI5501001113OtherSTATE OF MICHIGAN
MIP04810004Medicare PIN
MI650G011870OtherBCBSM