Provider Demographics
NPI:1700432101
Name:VANDEL-HOLM, MITCHELL (PT, DPT, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:VANDEL-HOLM
Suffix:
Gender:M
Credentials:PT, DPT, ATC, CSCS
Other - Prefix:
Other - First Name:MITCHELL
Other - Middle Name:
Other - Last Name:VANDEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC, CSCS
Mailing Address - Street 1:3542 SEAWARD CIR APT 310
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-5235
Mailing Address - Country:US
Mailing Address - Phone:307-399-7859
Mailing Address - Fax:
Practice Address - Street 1:1482 LA MIRADA DR
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-2414
Practice Address - Country:US
Practice Address - Phone:760-704-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-13
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT300190225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist