Provider Demographics
NPI:1225695968
Name:VREDENBURG, DANIEL RAY
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:RAY
Last Name:VREDENBURG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 LATTICE DR
Mailing Address - Street 2:
Mailing Address - City:STEPHENSON
Mailing Address - State:VA
Mailing Address - Zip Code:22656-1889
Mailing Address - Country:US
Mailing Address - Phone:303-931-8521
Mailing Address - Fax:
Practice Address - Street 1:100 LATTICE DR
Practice Address - Street 2:
Practice Address - City:STEPHENSON
Practice Address - State:VA
Practice Address - Zip Code:22656-1889
Practice Address - Country:US
Practice Address - Phone:303-931-8521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No172A00000XOther Service ProvidersDriver