Provider Demographics
NPI:1487600011
Name:THOMAS J VANIDESTINE JR
Entity type:Organization
Organization Name:THOMAS J VANIDESTINE JR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:VANIDESTINE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:207-942-2800
Mailing Address - Street 1:336 MOUNT HOPE AVE
Mailing Address - Street 2:SUITE 11
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-4236
Mailing Address - Country:US
Mailing Address - Phone:207-942-2800
Mailing Address - Fax:207-990-2362
Practice Address - Street 1:336 MOUNT HOPE AVE
Practice Address - Street 2:SUITE 11
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4236
Practice Address - Country:US
Practice Address - Phone:207-942-2800
Practice Address - Fax:207-990-2362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEME1721Medicare PIN