Provider Demographics
NPI:1811439136
Name:VANIDESTINE, THOMAS (DC)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:VANIDESTINE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9975 SW FREWING ST
Mailing Address - Street 2:SUITE #210
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-5091
Mailing Address - Country:US
Mailing Address - Phone:503-444-1953
Mailing Address - Fax:971-244-7246
Practice Address - Street 1:9975 SW FREWING ST
Practice Address - Street 2:SUITE #210
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-5091
Practice Address - Country:US
Practice Address - Phone:503-444-1953
Practice Address - Fax:971-244-7246
Is Sole Proprietor?:No
Enumeration Date:2016-11-17
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5773111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor