Healthcare Provider Details

I. General information

NPI: 1649490855
Provider Name (Legal Business Name): VANDYKE CHIROPRACTIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2007
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1779 LOVERS GAP ROAD
VANSANT VA
24656
US

IV. Provider business mailing address

PO BOX 855
VANSANT VA
24656-0855
US

V. Phone/Fax

Practice location:
  • Phone: 276-597-8387
  • Fax: 276-597-2154
Mailing address:
  • Phone: 276-597-8387
  • Fax: 276-597-2154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number0104001184
License Number StateVA

VIII. Authorized Official

Name: DR. BRADLEY DEAN VANDYKE
Title or Position: CLINIC DIRECTOR
Credential: DC
Phone: 276-597-8387