Provider Demographics
NPI:1720581341
Name:VANGOETHEM, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:VANGOETHEM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14330 MIDWAY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75244-3513
Mailing Address - Country:US
Mailing Address - Phone:214-550-5040
Mailing Address - Fax:214-310-1507
Practice Address - Street 1:4101 MCEWEN RD STE 330
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75244-5217
Practice Address - Country:US
Practice Address - Phone:214-550-5040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-09
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant