=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770747404
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTIAN VANDERFORD PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2008
-----------------------------------------------------
Last Update Date | 07/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 606 N FIFTH AVE
-----------------------------------------------------
City | SANDPOINT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83864-1520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-284-3597
-----------------------------------------------------
Fax | 208-718-6341
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2490
-----------------------------------------------------
City | SANDPOINT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83864-0915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-284-3597
-----------------------------------------------------
Fax | 208-718-6341
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT-2378
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------