MEDICARE: MR. KELLY GERRIT VREDEVELD PT, DPT

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	225100000X	Physical Therapist	5810	AZ

General Provider Information

NPI Number	:	1588602874
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KELLY GERRIT VREDEVELD PT, DPT

Provider Business Mailing Address
First Line	:	2852 N NAVAJO DR STE A
Second Line	:
City	:	PRESCOTT VALLEY
State	:	AZ
Zip	:	86314-4966
Country	:	US
Telephone Number	:	928-772-9797
Fax Number	:	928-772-9340

Provider Business Practice Location Address
First Line	:	2852 N NAVAJO DR STE A
Second Line	:
City	:	PRESCOTT VALLEY
State	:	AZ
Zip	:	86314-4966
Country	:	US
Telephone Number	:	928-772-9797
Fax Number	:	928-772-9340

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

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	07/10/2024

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