MEDICARE: JANE VANRENTERGHEM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SP6683	OH

General Provider Information

NPI Number	:	1053735811
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANE VANRENTERGHEM

Provider Business Mailing Address
First Line	:	2720 TOWNSHIP ROAD 35
Second Line	:
City	:	MOUNT CORY
State	:	OH
Zip	:	45868-9704
Country	:	US
Telephone Number	:	419-477-5220
Fax Number	:

Provider Business Practice Location Address
First Line	:	2720 TOWNSHIP ROAD 35
Second Line	:
City	:	MOUNT CORY
State	:	OH
Zip	:	45868-9704
Country	:	US
Telephone Number	:	419-477-5220
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2014
Last Update Date	:	02/13/2014

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Directions to “ JANE VANRENTERGHEM ” Practice Location

Language	Start Address	Practice Location

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