=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154514313
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MICHAEL F. VANDEWALLE P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2007
-----------------------------------------------------
Last Update Date | 03/17/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11824 JOLLYVILLE RD SUITE 500
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78759-2322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-343-0700
-----------------------------------------------------
Fax | 512-343-0775
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11824 JOLLYVILLE RD SUITE 500
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78759-2322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-343-0700
-----------------------------------------------------
Fax | 512-343-0775
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DR./OWNER
-----------------------------------------------------
Name | DR. MICHAEL F VANDEWALLE
-----------------------------------------------------
Credential | D.C
-----------------------------------------------------
Telephone | 512-343-0700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 11404
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 2771
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------