MEDICARE: C. DIEDERICK VAN DER VELDE

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	310400000X	Assisted Living Facility		OH

General Provider Information

NPI Number	:	1457607459
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	C. DIEDERICK VAN DER VELDE

Provider Business Mailing Address
First Line	:	3000 MCGEE AVE
Second Line	:
City	:	MIDDLETOWN
State	:	OH
Zip	:	45044-4991
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3000 MCGEE AVE
Second Line	:
City	:	MIDDLETOWN
State	:	OH
Zip	:	45044-4991
Country	:	US
Telephone Number	:	513-423-2322
Fax Number	:

Authorized Official
Title or Position	:	SOLE OWNER
Name	:	MR. DIEDERICK VAN DER VELDE
Credential	:
Telephone Number	:	502-500-7798

Provider Enumeration Date	:	07/27/2012
Last Update Date	:	07/27/2012

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