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General NPI Number Information
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NPI Number | 1053864835
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Entity Type | Individual
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Provider Name | MR. ROBERT FRED VANDEBORNE
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Gender | Male
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Dates
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Enumeration Date | 07/28/2016
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Last Update Date | 07/28/2016
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Provider Practice Location Address
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Address Line | 12647 OLIVE BLVD SUITE 600
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City | SAINT LOUIS
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State | MO
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Zip | 63141-6393
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Country | US
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Telephone | 800-325-3982
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Fax | 877-685-9880
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Provider Business Mailing Address
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Address Line | 12647 OLIVE BLVD SUITE 600
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City | SAINT LOUIS
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State | MO
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Zip | 63141-6393
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Country | US
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Telephone | 800-325-3982
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Fax | 877-685-9880
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 247100000X
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Taxonomy Name | Radiologic Technologist
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License Number |
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License Number State |
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