Provider Demographics
NPI:1205020724
Name:VANDUSEN, LOREN E (DC)
Entity Type:Individual
Prefix:DR
First Name:LOREN
Middle Name:E
Last Name:VANDUSEN
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 1:99 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SODUS
Mailing Address - State:NY
Mailing Address - Zip Code:14551-1119
Mailing Address - Country:US
Mailing Address - Phone:315-483-6783
Mailing Address - Fax:
Practice Address - Street 1:99 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SODUS
Practice Address - State:NY
Practice Address - Zip Code:14551-1119
Practice Address - Country:US
Practice Address - Phone:315-483-6783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-28
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX006705-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10451BMedicare PIN