Provider Demographics
NPI:1700309671
Name:VANDEBOGART, CHARLES SCOTT JR (ATC)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:SCOTT
Last Name:VANDEBOGART
Suffix:JR
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:45 MEADOW RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:LAGRANGEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12540-5224
Mailing Address - Country:US
Mailing Address - Phone:845-380-0504
Mailing Address - Fax:
Practice Address - Street 1:2 FRONT ST
Practice Address - Street 2:
Practice Address - City:MILLBROOK
Practice Address - State:NY
Practice Address - Zip Code:12545-5948
Practice Address - Country:US
Practice Address - Phone:845-677-5021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-21
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer