Provider Demographics
NPI:1780816512
Name:VANDERZYL, BRENT (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:VANDERZYL
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E CEDARWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34743-9070
Mailing Address - Country:US
Mailing Address - Phone:407-791-2366
Mailing Address - Fax:
Practice Address - Street 1:190 E CEDARWOOD CIR
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34743-9070
Practice Address - Country:US
Practice Address - Phone:407-791-2366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-12
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL27012255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer