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General NPI Number Information
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NPI Number | 1669941514
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Entity Type | Organization
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Legal Business Name | PROTEAM TACTICAL PERFORMANCE
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Dates
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Enumeration Date | 11/21/2018
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Last Update Date | 12/15/2020
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Provider Practice Location Address
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Address Line | 8025 COMBS RD
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City | INDIANAPOLIS
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State | IN
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Zip | 46237-9588
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Country | US
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Telephone | 317-804-3501
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Fax |
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Provider Business Mailing Address
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Address Line | 1531 E NORTHFIELD DR
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City | BROWNSBURG
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State | IN
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Zip | 46112-2513
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | JOEY VANDEVER
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Credential |
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Telephone | 317-892-8180
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number |
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License Number State |
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