MEDICARE: DR. DOUGLAS VANDER BROEK D.C.

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	111N00000X	Chiropractor	790	NE

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	091515	OTHER	NE	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	47-0677634	OTHER	NE	IRS/FEDERAL EMPLOYER ID N

General Provider Information

NPI Number	:	1699779934
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DOUGLAS VANDER BROEK D.C.

Provider Business Mailing Address
First Line	:	6511 SHENANDOAH DR
Second Line	:
City	:	LINCOLN
State	:	NE
Zip	:	68510-4195
Country	:	US
Telephone Number	:	402-730-4409
Fax Number	:

Provider Business Practice Location Address
First Line	:	6511 SHENANDOAH DR
Second Line	:
City	:	LINCOLN
State	:	NE
Zip	:	68510-4195
Country	:	US
Telephone Number	:	402-730-4409
Fax Number	:

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

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	11/02/2015

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