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General NPI Number Information
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NPI Number | 1538108022
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Entity Type | Individual
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Provider Name | THOMAS J VANIDESTINE JR. DC, CCSP
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Gender | Male
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Dates
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Enumeration Date | 06/06/2006
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Last Update Date | 12/01/2016
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Provider Practice Location Address
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Address Line | 336 MOUNT HOPE AVE SUITE 11
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City | BANGOR
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State | ME
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Zip | 04401-4236
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Country | US
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Telephone | 207-942-2800
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Fax | 207-990-2362
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Provider Business Mailing Address
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Address Line | 336 MOUNT HOPE AVE SUITE 11
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City | BANGOR
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State | ME
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Zip | 04401-4236
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Country | US
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Telephone | 207-942-2800
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Fax | 207-990-2362
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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 | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CR814
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License Number State | ME
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