1437240447 NPI number — VICKIE L VANDERLAAN

Table of content: VICKIE L VANDERLAAN (NPI 1437240447)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437240447 NPI number — VICKIE L VANDERLAAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANDERLAAN
Provider First Name:
VICKIE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1437240447
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/01/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1675 LEAHY ST
Provider Second Line Business Mailing Address:
STE 109
Provider Business Mailing Address City Name:
MUSKEGON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49442-5500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-728-5720
Provider Business Mailing Address Fax Number:
231-728-5721

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1675 LEAHY ST
Provider Second Line Business Practice Location Address:
STE 109
Provider Business Practice Location Address City Name:
MUSKEGON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49442-5500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-728-5720
Provider Business Practice Location Address Fax Number:
231-728-5721
Provider Enumeration Date:
09/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 237600000X , with the licence number:  1601000084 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 540F111730 . This is a "BCBS SUPPLIER ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 904900723 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 640F12603 . This is a "BCBS AUDIO ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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