Provider Demographics
NPI:1649490855
Name:VANDYKE CHIROPRACTIC PC
Entity type:Organization
Organization Name:VANDYKE CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:VANDYKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:276-597-8387
Mailing Address - Street 1:PO BOX 855
Mailing Address - Street 2:
Mailing Address - City:VANSANT
Mailing Address - State:VA
Mailing Address - Zip Code:24656-0855
Mailing Address - Country:US
Mailing Address - Phone:276-597-8387
Mailing Address - Fax:276-597-2154
Practice Address - Street 1:1779 LOVERS GAP ROAD
Practice Address - Street 2:
Practice Address - City:VANSANT
Practice Address - State:VA
Practice Address - Zip Code:24656
Practice Address - Country:US
Practice Address - Phone:276-597-8387
Practice Address - Fax:276-597-2154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-27
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104001184111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7600037000Medicaid
VAU42499Medicare UPIN