MEDICARE: MARK VANDENBERG

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	174400000X	Specialist	PTA20097	FL

General Provider Information

NPI Number	:	1689890949
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK VANDENBERG

Provider Business Mailing Address
First Line	:	1601 NE 11TH AVE
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33305-3171
Country	:	US
Telephone Number	:	920-850-5758
Fax Number	:

Provider Business Practice Location Address
First Line	:	1601 NE 11TH AVE
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33305-3171
Country	:	US
Telephone Number	:	920-850-5758
Fax Number	:

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

Provider Enumeration Date	:	04/17/2007
Last Update Date	:	07/08/2007

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Directions to “ MARK VANDENBERG ” Practice Location

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