Healthcare Provider Details

I. General information

NPI: 1851369110
Provider Name (Legal Business Name): STEVEN LEE VAN GENDEREN PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 11/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1319 WEST HAVENS
MITCHELL SD
57301
US

IV. Provider business mailing address

1319 WEST HAVENS
MITCHELL SD
57301
US

V. Phone/Fax

Practice location:
  • Phone: 605-996-4778
  • Fax: 605-996-3660
Mailing address:
  • Phone: 605-996-4778
  • Fax: 605-996-3660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1158
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier46778
Identifier TypeOTHER
Identifier StateSD
Identifier IssuerSANFORD
# 2
IdentifierP00278969
Identifier TypeOTHER
Identifier StateSD
Identifier IssuerMEDICARE RAILROAD
# 3
IdentifierPT1158
Identifier TypeOTHER
Identifier StateSD
Identifier IssuerDAKOTACARE
# 4
Identifier5834960
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer
# 5
Identifier4994487
Identifier TypeOTHER
Identifier State
Identifier IssuerWELLMARK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: