Provider Demographics
NPI:1649381427
Name:VANGIESEN, STEPHEN ROBERT (DC)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:ROBERT
Last Name:VANGIESEN
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 1:808 W EHRINGHAUS STREET
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909
Mailing Address - Country:US
Mailing Address - Phone:252-338-3206
Mailing Address - Fax:252-338-6394
Practice Address - Street 1:808 W EHRINGHAUS STREET
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909
Practice Address - Country:US
Practice Address - Phone:252-338-3206
Practice Address - Fax:252-338-6394
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1224111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC08885OtherSHP
NC08885OtherBCBS
NC08885OtherSHP
T64394Medicare UPIN