Provider Demographics
NPI:1699779934
Name:VANDER BROEK, DOUGLAS (DC)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
Last Name:VANDER BROEK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6511 SHENANDOAH DR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68510-4195
Mailing Address - Country:US
Mailing Address - Phone:402-730-4409
Mailing Address - Fax:
Practice Address - Street 1:6511 SHENANDOAH DR
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68510-4195
Practice Address - Country:US
Practice Address - Phone:402-730-4409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE790111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47-067763401Medicaid
NE47-0677634OtherIRS/FEDERAL EMPLOYER ID N
NE091515OtherMEDICARE PTAN
NE47-067763401Medicaid