Provider Demographics
NPI:1316166960
Name:VANDEMARK, KENNETH REID (PT, ATC, CSCS)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:REID
Last Name:VANDEMARK
Suffix:
Gender:M
Credentials:PT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 TUPELO LN
Mailing Address - Street 2:
Mailing Address - City:LANGHORNE
Mailing Address - State:PA
Mailing Address - Zip Code:19047-3406
Mailing Address - Country:US
Mailing Address - Phone:215-752-2159
Mailing Address - Fax:
Practice Address - Street 1:10 TUPELO LN
Practice Address - Street 2:
Practice Address - City:LANGHORNE
Practice Address - State:PA
Practice Address - Zip Code:19047-3406
Practice Address - Country:US
Practice Address - Phone:215-752-2159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT002679-L225100000X
NJ40QA00109000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist