=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598386542
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VANDERVEEN CHIROPRACTIC SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2020
-----------------------------------------------------
Last Update Date | 04/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3348 TYRONE BLVD N
-----------------------------------------------------
City | SAINT PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33710-2340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-800-9928
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3348 TYRONE BLVD N
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33710-2340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JORDON VANDERVEEN
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 616-800-9928
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------