Healthcare Provider Details

I. General information

NPI: 1801857727
Provider Name (Legal Business Name): MICHAEL J VAN VEGHEL ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1726 EAGAN RD SUITE 100
MADISON WI
53704-3702
US

IV. Provider business mailing address

1726 EAGAN RD SUITE 100
MADISON WI
53704-3702
US

V. Phone/Fax

Practice location:
  • Phone: 608-265-1208
  • Fax: 608-263-2010
Mailing address:
  • Phone: 608-265-1208
  • Fax: 608-263-2010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number378-039
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: