Provider Demographics
NPI:1104431451
Name:VANDER VORSTE, ALEX JASON (MS, ATC)
Entity type:Individual
Prefix:
First Name:ALEX
Middle Name:JASON
Last Name:VANDER VORSTE
Suffix:
Gender:M
Credentials:MS, ATC
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Mailing Address - Street 1:24255 PACIFIC COAST HWY
Mailing Address - Street 2:PEPPERDINE ATHLETICS - SPORTS MEDICINE
Mailing Address - City:MALIBU
Mailing Address - State:CA
Mailing Address - Zip Code:90263
Mailing Address - Country:US
Mailing Address - Phone:310-506-4169
Mailing Address - Fax:310-506-4424
Practice Address - Street 1:24255 PACIFIC COAST HWY
Practice Address - Street 2:PEPPERDINE ATHLETICS - SPORTS MEDICINE
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90263
Practice Address - Country:US
Practice Address - Phone:310-506-4169
Practice Address - Fax:310-506-4424
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA20000178452255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer