Provider Demographics
NPI:1972986859
Name:DAUTRUCHE, VAN
Entity Type:Individual
Prefix:
First Name:VAN
Middle Name:
Last Name:DAUTRUCHE
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 1:57 COOPER ST
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-4650
Mailing Address - Country:US
Mailing Address - Phone:856-384-9433
Mailing Address - Fax:
Practice Address - Street 1:57 COOPER ST
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-4650
Practice Address - Country:US
Practice Address - Phone:856-384-9433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-09
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator