Individual
MR. JEREMY SCOTT VANDEHURST
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
L-AT
Contact information
Practice address
2170 SOUTH AVE # B, SOUTH LAKE TAHOE, CA 96150-7008
(530) 208-8253
Mailing address
2795 SPRINGWOOD DR, SOUTH LAKE TAHOE, CA 96150-2815
(530) 208-8253
Taxonomy
Speciality
Code
Description
License number
State
174H00000X
Health Educator
0506428
NV
207PS0010X
Sports Medicine (Emergency Medicine) Physician
Primary
0506428
NV
207XX0005X
Sports Medicine (Orthopaedic Surgery) Physician
0506428
NV
208100000X
Physical Medicine & Rehabilitation Physician
0506428
NV
226300000X
Kinesiotherapist
0506428
NV
405300000X
Prevention Professional
0506428
NV
Other
Enumeration date
03/11/2020
Last updated
03/11/2020
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