=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417429374
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VANFOSSEN LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2018
-----------------------------------------------------
Last Update Date | 01/02/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 550 SILVER BLUFF RD STE 200
-----------------------------------------------------
City | AIKEN
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29803-7835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-303-2679
-----------------------------------------------------
Fax | 330-319-8842
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2170 PINE LOG RD
-----------------------------------------------------
City | WARRENVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29851-3416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-303-2679
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ETHAN VANFOSSEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 864-303-2679
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------