Provider Demographics
NPI:1235438136
Name:NEIL A VAN DYCK, DPM, PODIATRY CORPORATION
Entity Type:Organization
Organization Name:NEIL A VAN DYCK, DPM, PODIATRY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSTY
Authorized Official - Middle Name:
Authorized Official - Last Name:SPARKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-640-0515
Mailing Address - Street 1:1650 LEAD HILL BLVD
Mailing Address - Street 2:# 100
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3061
Mailing Address - Country:US
Mailing Address - Phone:916-786-3434
Mailing Address - Fax:916-786-6770
Practice Address - Street 1:1650 LEAD HILL BLVD
Practice Address - Street 2:# 100
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3061
Practice Address - Country:US
Practice Address - Phone:916-786-3434
Practice Address - Fax:916-786-6770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-18
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2481213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0955670001Medicare NSC