Healthcare Provider Details

I. General information

NPI: 1154153864
Provider Name (Legal Business Name): ALLEN LEE VANDEN BRINK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2024
Last Update Date: 08/20/2024
Certification Date: 08/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15100 RESCUE WAY
CLEARWATER FL
33762-3502
US

IV. Provider business mailing address

15100 RESCUE WAY
CLEARWATER FL
33762-3502
US

V. Phone/Fax

Practice location:
  • Phone: 727-535-1437
  • Fax:
Mailing address:
  • Phone: 727-535-1437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: