Healthcare Provider Details

I. General information

NPI: 1487600011
Provider Name (Legal Business Name): THOMAS J VANIDESTINE JR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 03/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

336 MOUNT HOPE AVE SUITE 11
BANGOR ME
04401-4236
US

IV. Provider business mailing address

336 MOUNT HOPE AVE SUITE 11
BANGOR ME
04401-4236
US

V. Phone/Fax

Practice location:
  • Phone: 207-942-2800
  • Fax: 207-990-2362
Mailing address:
  • Phone: 207-942-2800
  • Fax: 207-990-2362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: THOMAS J VANIDESTINE JR.
Title or Position: OWNER
Credential: DC
Phone: 207-942-2800