1518039619 NPI number — MS. LAURA JEAN VANDENBERG LADC

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518039619 NPI number — MS. LAURA JEAN VANDENBERG LADC

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

VANDENBERG

Provider First Name:

LAURA

Provider Middle Name:

JEAN

Provider Name Prefix Text:

MS.

Provider Name Suffix Text:

Provider Credential Text:

LADC

Provider Gender Code:

F

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:

1518039619

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

09/30/2008

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

459 SOUTH 6TH, STREET, SUITE 1

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

SEWARD

Provider Business Mailing Address State Name:

NE

Provider Business Mailing Address Postal Code:

68434

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

402-643-3343

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

729 SEWARD ST

Provider Second Line Business Practice Location Address:

SUITE 2

Provider Business Practice Location Address City Name:

SEWARD

Provider Business Practice Location Address State Name:

NE

Provider Business Practice Location Address Postal Code:

68434

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

402-643-3343

Provider Business Practice Location Address Fax Number:

402-643-4048

Provider Enumeration Date:

11/14/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 101YA0400X , with the licence number:  422 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 47052851503 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
• Identifier: 47052851514 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
• Identifier: 47052851501 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
• Identifier: 47052851504 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
• Identifier: 10025668200 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
• Identifier: 47052851506 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
• Identifier: 47052851510 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
• Identifier: 85311 . This is a "BCBS" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".
• Identifier: 10025208600 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
• Identifier: 47052851509 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
• Identifier: 10025208500 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
• Identifier: 470528515-08 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
• Identifier: 47052851515 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
• Identifier: 47052851500 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".