=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700429099
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VONDERHAAR PHYSICAL THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2019
-----------------------------------------------------
Last Update Date | 10/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 880 KINNEAR RD
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43212-1443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-697-8327
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 67 W DUNEDIN RD
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43214-4001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-697-8327
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MANDI VONDERHAAR
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 330-697-8327
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------