Healthcare Provider Details

I. General information

NPI: 1699557017
Provider Name (Legal Business Name): JOHN NATHAN VANVYNCKT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2023
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2435 RESEARCH PKWY # 225
COLORADO SPRINGS CO
80920-1070
US

IV. Provider business mailing address

6541 ANTELOPE RUN CIR APT 307
COLORADO SPRINGS CO
80924-8506
US

V. Phone/Fax

Practice location:
  • Phone: 719-260-8400
  • Fax:
Mailing address:
  • Phone: 772-696-2178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA.0015428
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: