Provider Demographics
NPI:1669941514
Name:PROTEAM TACTICAL PERFORMANCE
Entity type:Organization
Organization Name:PROTEAM TACTICAL PERFORMANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOEY
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDEVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-892-8180
Mailing Address - Street 1:1531 E NORTHFIELD DR
Mailing Address - Street 2:
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-2513
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8025 COMBS RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-9588
Practice Address - Country:US
Practice Address - Phone:317-804-3501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-21
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1639497795OtherNPPES
IN1750854873OtherNPPES
IN1366871915OtherNPPES
IN1871916783OtherNPPES
IN1891789418OtherNPPES
IN1396391918OtherNPPES
IN1407295181OtherNPPES
IN1336112135OtherNPPES
IN1417421793OtherNPPES