Provider Demographics
NPI:1275709248
Name:VANCE, RONALD L (RPT)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:L
Last Name:VANCE
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 N COURT AVE
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-1515
Mailing Address - Country:US
Mailing Address - Phone:989-732-4753
Mailing Address - Fax:989-731-3553
Practice Address - Street 1:609 N COURT AVE
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-1515
Practice Address - Country:US
Practice Address - Phone:989-732-4753
Practice Address - Fax:989-731-3553
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-30
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501000840225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
236529Medicare Oscar/Certification