Healthcare Provider Details

I. General information

NPI: 1669941514
Provider Name (Legal Business Name): PROTEAM TACTICAL PERFORMANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2018
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8025 COMBS RD
INDIANAPOLIS IN
46237-9588
US

IV. Provider business mailing address

1531 E NORTHFIELD DR
BROWNSBURG IN
46112-2513
US

V. Phone/Fax

Practice location:
  • Phone: 317-804-3501
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: JOEY VANDEVER
Title or Position: CEO
Credential:
Phone: 317-892-8180