Provider Demographics
NPI:1528380417
Name:VERVLOET, ROBERT (USTAF)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:VERVLOET
Suffix:
Gender:M
Credentials:USTAF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2636 SW BEAVERTON HILLSDALE HWY
Mailing Address - Street 2:#C
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-1169
Mailing Address - Country:US
Mailing Address - Phone:503-515-3148
Mailing Address - Fax:
Practice Address - Street 1:2636 SW BEAVERTON HILLSDALE HWY
Practice Address - Street 2:#C
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-1169
Practice Address - Country:US
Practice Address - Phone:503-515-3148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-19
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL1042419172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist