Provider Demographics
NPI:1245240100
Name:VANDERBLIEK, BERT J (DC)
Entity Type:Individual
Prefix:
First Name:BERT
Middle Name:J
Last Name:VANDERBLIEK
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 1:7439 RESEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335
Mailing Address - Country:US
Mailing Address - Phone:818-345-4924
Mailing Address - Fax:818-345-5529
Practice Address - Street 1:7439 RESEDA BLVD
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335
Practice Address - Country:US
Practice Address - Phone:818-345-4924
Practice Address - Fax:818-345-5529
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC18989111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC18989Medicare PIN