Healthcare Provider Details

I. General information

NPI: 1861027625
Provider Name (Legal Business Name): JEREMY SCOTT VANDEHURST L-AT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2020
Last Update Date: 03/11/2020
Certification Date: 03/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2170 SOUTH AVE # B
SOUTH LAKE TAHOE CA
96150-7008
US

IV. Provider business mailing address

2795 SPRINGWOOD DR
SOUTH LAKE TAHOE CA
96150-2815
US

V. Phone/Fax

Practice location:
  • Phone: 530-208-8253
  • Fax:
Mailing address:
  • Phone: 530-208-8253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number0506428
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number0506428
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number0506428
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number0506428
License Number StateNV
# 5
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number0506428
License Number StateNV
# 6
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number0506428
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: