Provider Demographics
NPI:1699135335
Name:VANDAMME, BART (QIDP)
Entity type:Individual
Prefix:
First Name:BART
Middle Name:
Last Name:VANDAMME
Suffix:
Gender:M
Credentials:QIDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5365 MAE ANNE AVE
Mailing Address - Street 2:STE A10
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89523-1840
Mailing Address - Country:US
Mailing Address - Phone:775-323-6222
Mailing Address - Fax:775-323-6263
Practice Address - Street 1:5365 MAE ANNE AVE
Practice Address - Street 2:STE A10
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89523-1840
Practice Address - Country:US
Practice Address - Phone:775-323-6222
Practice Address - Fax:775-323-6263
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-23
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100503417Medicaid