Provider Demographics
NPI:1174550446
Name:VANDOVER, WADE (PT)
Entity type:Individual
Prefix:
First Name:WADE
Middle Name:
Last Name:VANDOVER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 ROY ST
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56278-1138
Mailing Address - Country:US
Mailing Address - Phone:320-830-4271
Mailing Address - Fax:320-839-4196
Practice Address - Street 1:500 CROSS ST
Practice Address - Street 2:
Practice Address - City:BIG STONE CITY
Practice Address - State:SD
Practice Address - Zip Code:57216-8237
Practice Address - Country:US
Practice Address - Phone:605-541-1115
Practice Address - Fax:605-541-0109
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0383225100000X
MN4675225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN650001726Medicare PIN
MN650000917Medicare PIN