Healthcare Provider Details

I. General information

NPI: 1477104529
Provider Name (Legal Business Name): MATTHEW TAYLOR VANDER KOOI DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16811 N LITCHFIELD RD STE 101
SURPRISE AZ
85374-7062
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440-4909
US

V. Phone/Fax

Practice location:
  • Phone: 623-322-0654
  • Fax: 623-322-0664
Mailing address:
  • Phone: 630-296-2222
  • Fax: 630-759-9510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberLPT-30902
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: