Provider Demographics
NPI:1538108022
Name:VANIDESTINE, THOMAS J JR (DC, CCSP)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:VANIDESTINE
Suffix:JR
Gender:M
Credentials:DC, CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 MOUNT HOPE AVE
Mailing Address - Street 2:SUITE 11
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-4236
Mailing Address - Country:US
Mailing Address - Phone:207-942-2800
Mailing Address - Fax:207-990-2362
Practice Address - Street 1:336 MOUNT HOPE AVE
Practice Address - Street 2:SUITE 11
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4236
Practice Address - Country:US
Practice Address - Phone:207-942-2800
Practice Address - Fax:207-990-2362
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECR814111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME001039OtherBLUE CROSS/ANTHEM
ME121660000Medicaid
ME121660099Medicaid
ME5734579OtherCIGNA
ME5314274OtherAETNA
MEP00282285OtherRAILROAD MEDICARE
ME610664OtherGREAT WEST/ACN
ME68974OtherFIRST HEALTH
MEMN0080OtherHARVARD PILGRIM
ME121660000Medicaid
ME5314274OtherAETNA
ME121660099Medicaid