Provider Demographics
NPI:1720336225
Name:VANDER SLOOT, TRAVIS
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:
Last Name:VANDER SLOOT
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 1:309 W GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48933-1109
Mailing Address - Country:US
Mailing Address - Phone:616-848-0382
Mailing Address - Fax:
Practice Address - Street 1:2775 E LANSING DR
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-7755
Practice Address - Country:US
Practice Address - Phone:517-332-1616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide