Healthcare Provider Details

I. General information

NPI: 1053864835
Provider Name (Legal Business Name): MR. ROBERT FRED VANDEBORNE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2016
Last Update Date: 07/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12647 OLIVE BLVD SUITE 600
SAINT LOUIS MO
63141-6393
US

IV. Provider business mailing address

12647 OLIVE BLVD SUITE 600
SAINT LOUIS MO
63141-6393
US

V. Phone/Fax

Practice location:
  • Phone: 800-325-3982
  • Fax: 877-685-9880
Mailing address:
  • Phone: 800-325-3982
  • Fax: 877-685-9880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: