1134104292 NPI number — MR. TRAVIS WAYNE VANDER REYDEN P.T.

Table of content: MR. TRAVIS WAYNE VANDER REYDEN P.T. (NPI 1134104292)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134104292 NPI number — MR. TRAVIS WAYNE VANDER REYDEN P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VANDER REYDEN
Provider First Name:
TRAVIS
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
M

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:
1134104292
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
328 N MICHIGAN ST
Provider Second Line Business Mailing Address:
STE. 200
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46601-1244
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-647-1845
Provider Business Mailing Address Fax Number:
574-647-1825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 I ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAPORTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46350-5533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-324-1700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/13/2005

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: 225100000X , with the licence number:  05007152A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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