=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700309671
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES SCOTT VANDEBOGART JR. ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2017
-----------------------------------------------------
Last Update Date | 07/21/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 FRONT ST
-----------------------------------------------------
City | MILLBROOK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12545-5948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-677-5021
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 45 MEADOW RIDGE LN
-----------------------------------------------------
City | LAGRANGEVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12540-5224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-380-0504
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------